The role of Portuguese Pharmacies in Diabetes Management

1
The role of Portuguese Pharmacies in Diabetes
Management

• Suzete COSTA
• Pharmacist, Master in Public Health
• National Association of Pharmacies (ANF)
• Pharmacy-based Disease Management Dept. Manager

2
Outline

• Diabetes 1st Agreement 1998
• Pharmacy-based DSM
• Exploratory pilot intervention trial
• Diabetes new Agreement 2003
• Current Figures
• Definitive research trial
• Challenges in implementing services
• A glimpse into the future...

3
Diabetes 1st Agreement signed

• Diabetes 1st Agreement
• Pharmacy-based DSM
• Exploratoy pilot trial
• Diabetes new Agreement
• Figures till 30-08-2005
• Definitive trial
• Challenges in Implementing services
• A glimpse into the future

• 1998 ANF, NHS, Pharm. Society, wholesalers,
  industry
• Better access to self-monitoring devices
• NHS co-payment of syringes, needles and strips
• Pharmacies 0 margin profit on these products
• Counseling on medication and self-monitoring
• Remuneration for patient care temporarily
  accepted free of charge

4
Pharmacy-based DSM

• Diabetes 1st Agreement
• Pharmacy-based DSM
• Exploratoy pilot trial
• Diabetes new Agreement
• Figures till 30-08-2005
• Definitive trial
• Challenges in Implementing services
• A glimpse into the future

• 1999 Pharmacy-based Disease State Management
• Asthma / COPD
• Diabetes
• Hypertension
• DSM areas according to national health priorities
• Pharmacy practice model approved by the Pharm.
  Society
• Patients on drug therapy, above target values
  and/or with uncontrolled health problems

5
Service provided

• Diabetes 1st Agreement
• Pharmacy-based DSM
• Exploratoy pilot trial
• Diabetes new Agreement
• Figures till 30-08-2005
• Definitive trial
• Challenges in Implementing services
• A glimpse into the future

• Mix DSM / Pharmaceutical Care
• Patient follow up at scheduled visits to the
  pharmacy to
• analyze patient complaints
• perform point-of-care measurements against target
  values
• identify Drug-Related Problems (DRPs)
• report DRPs to prescriber and / or provide
  counseling.
• Integrated advanced service
• Specific training program required
• DRP Classification used Second Consensus of
  Granada (since Apr. 2003)

6
Exploratory pilot intervention trial

• Diabetes 1st Agreement
• Pharmacy-based DSM
• Exploratory pilot trial
• Diabetes new Agreement
• Figures till 30-08-2005
• Definitive trial
• Challenges in Implementing services
• A glimpse into the future

Pilot results (Diabetes Program)
Wilcoxon sign rank test T-Student (paired
t-test)
7
DSM from pilot to remuneration

• Diabetes 1st Agreement
• Pharmacy-based DSM
• Exploratory pilot trial
• Diabetes new Agreement
• Figures till 30-08-2005
• Definitive trial
• Challenges in Implementing services
• A glimpse into the future

• Jan. - Feb. 2003 Modifications introduced
• No. of drug therapy elements recorded ?
• New DRP Classification adopted
• Changes in specific training program
• March 2003 Large scale implementation of DSM
• Sept. 2003 New Agreement signed (Diabetes)

8
Recognition for care provided

• Diabetes 1st Agreement
• Pharmacy-based DSM
• Exploratoy pilot trial
• Diabetes new Agreement
• Figures till 30-08-2005
• Definitive trial
• Challenges in Implementing services
• A glimpse into the future

• Switzerland Contract with health insurer for
  Medication Review
• Portugal Contract with NHS for Disease
  Management (Diabetes)
• Germany Contracts with health insurers for
  Disease Management and Home Medication
  Review
• UK Contract with NHS for additional services
  (incl. Medicines Management)

9
Diabetes New Agreement signed

• Diabetes 1st Agreement
• Pharmacy-based DSM
• Exploratoy pilot trial
• Diabetes new Agreement
• Figures till 30-08-2005
• Definitive trial
• Challenges in Implementing services
• A glimpse into the future

• 2003 ANF, NHS, Pharmaceutical Society
• Scope of pharmacists intervention expanded
• Level I essential service
• Level II integrated service (Diabetes DSM
  Program)
• Remuneration for level II
• Fixed fee per patient / per month
• Remuneration on trial till 31 December 2006.

10
Key issues level II

• Diabetes 1st Agreement
• Pharmacy-based DSM
• Exploratoy pilot trial
• Diabetes new Agreement
• Figures till 30-08-2005
• Definitive trial
• Challenges in Implementing services
• A glimpse into the future

• Responsible pharmacist appointed
• Only certified pharmacists
• Qualification in specific training program
• Training program accredited by Pharm. Society
• Documentation of patient data and care provided

11
No. pharmacies with certified pharmacist

• Diabetes 1st Agreement
• Pharmacy-based DSM
• Exploratoy pilot trial
• Diabetes new Agreement
• Figures till 30-08-2005
• Definitive trial
• Challenges in Implementing services
• A glimpse into the future

New Agreement signed
Expansion initiated
12
No. patients enrolled

• Diabetes 1st Agreement
• Pharmacy-based DSM
• Exploratoy pilot trial
• Diabetes new Agreement
• Figures till 30-08-2005
• Definitive trial
• Challenges in Implementing services
• A glimpse into the future

New Agreement signed
Expansion initiated
13
DRPs identified

• Diabetes 1st Agreement
• Pharmacy-based DSM
• Exploratoy pilot trial
• Diabetes new Agreement
• Figures till 30-08-2005
• Definitive trial
• Challenges in Implementing services
• A glimpse into the future

Indication
Effectiveness
Safety
DRP Classification Second Consensus of Granada
(between 1 Apr. 2003 to 30 Aug. 2005)
14
Results

• Diabetes 1st Agreement
• Pharmacy-based DSM
• Exploratoy pilot trial
• Diabetes new Agreement
• Figures till 30-08-2005
• Definitive trial
• Challenges in Implementing services
• A glimpse into the future

• 2790 Drug Related Problems (DRPs) identified
• 50 reported to the prescriber
• 54 of reported DRPs ? modification of drug
  therapy
• Trend continues in ? main surrogate clinical
  endpoints
• Post-prandial blood glucose 197 ? 181 (?16
  mg/dL)
• Fasting blood glucose 162 ? 146 (?16mg/dL)
• Systolic blood pressure 147 ? 140 (? 7 mm Hg)
• Diastolic blood pressure 82 ? 78 (? 4 mm Hg)
• Total blood cholesterol 200 ? 191 (? 9 mg/dL)

15
Definitive research trial

• Diabetes 1st Agreement
• Pharmacy-based DSM
• Exploratoy pilot trial
• Diabetes new Agreement
• Figures till 30-08-2005
• Definitive trial
• Challenges in Implementing services
• A glimpse into the future

• Remuneration on trial till 31 December 2006
• External evaluation of Diabetes Program
  commissioned by the Ministry of Health
• Internal (ANF) evaluation finalized and results
  presented
• Researching interventions in uncontrolled settings

16
Designing services for whom?

• Diabetes 1st Agreement
• Pharmacy-based DSM
• Exploratoy pilot trial
• Diabetes new Agreement
• Figures till 30-08-2005
• Definitive trial
• Challenges in implementing services
• A glimpse into the future

Majority
Early adopters
Late adopters
Innovators
Laggards
17
Facilitators for implementation

• Diabetes 1st Agreement
• Pharmacy-based DSM
• Exploratoy pilot trial
• Diabetes new Agreement
• Figures till 30-08-2005
• Definitive trial
• Challenges in implementing services
• A glimpse into the future

• Relationship with doctors
• Patient expectation
• Remuneration for service provided
• Pharmacy layout
• Manpower / staff
• Communication teamwork
• External support / assistance
• Roberts AS, Benrimoj SI, Chen TF, Williams KA,
  Aslani P. Implementing change in community
  pharmacy facilitating factors (poster presented
  at PCNE Conference 2005)

18
A changing environment in Portugal

• Diabetes 1st Agreement
• Pharmacy-based DSM
• Exploratoy pilot trial
• Diabetes new Agreement
• Figures till 30-08-2005
• Definitive trial
• Challenges in implementing services
• A glimpse into the future

• Ageing population
• ? ambulatory care
• ? health care costs
• NPM are now available outside pharmacies
• Ownership of pharmacy will no longer be
  restricted to pharmacists only
• Changes foreseen in the remuneration system
• ? patients and consumers concern for health
• Different customers
• Different needs and expectations

19
Expanding the scope of business...

• Diabetes 1st Agreement
• Pharmacy-based DSM
• Exploratoy pilot trial
• Diabetes new Agreement
• Figures till 30-08-2005
• Definitive trial
• Challenges in implementing services
• A glimpse into the future

Medication Management
Point of care monitoring
DSM / Pharmaceutical Care
Other essential services associated to the
provision of drug therapy
20

• Do not follow where the path may lead.
• Go instead where there is no path and leave a
  trail.
• Muriel Strode