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Title: Presenter:Chris Budgen President Pharmaceutical Society of New Zealand inc'


1
Presenter Chris Budgen President
Pharmaceutical Society of New Zealand inc.
2
New Zealand Health Care strategy Primary Health
Care vision Primary health care services will
focus on better health for a population, and
actively work to reduce health inequalities
between different groups. Primary Health Care
Strategy 13 population health objectives are to
reduce smoking, improve nutrition, reduce
obesity, effects of diabetes, cardiovascular etc.
3
Changing Patterns of Health Care Delivery
  • Nationally and internationally - why?
  • Chronic diseases are a huge burden on the State
  • A minority of patients consume the majority of
    resources
  • Keeping people well and productive in the
    community is to everyones advantage
  • Managing those disease states in a systematic way
    achieves the maximum return

4
Whats Been Identified ?
  • Different levels of care needed
  • 70 to 80 of people with long term conditions can
    care for themselves if given a minimum of
    direction and support from the system
  • A standard system or protocol for supporting
    those people would result in maximum benefit for
    minimum effort, i.e. most economical use of State
    resources

5
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6
Medicines Why the emphasis?
  • Medicines keep people well and functioning in the
    community
  • Medicine adverse events are a major disease
  • - Top five reasons for entering Secondary Care
    Accidents, Medicines, Cardiovascular, Cancer,
    Respiratory
  • High public expectations of medicines rising
    demand
  • Limited resources

7
Medicines New Zealand New Zealand National
Medicines Policy (Hon. Peter Dunne) The
three areas of focus are - 1/ access to
medicines 2/ quality of medicines and 3/ the
rational use of medicines
8
  • Pharmacist Services Project
  • DHB Pharmacy Advisory Group - Aug 2005
  • Value added pharmacy services
  • Information services
  • Medication review services

9
National Framework of Pharmacist Services
  • Health Education for provision to patients
  • Medicines and Clinical Information Support for
    provision to practitioners (this would include
    the pharmacist facilitator role)
  • Medicines Use Review and Adherence Support, a
    four part review, assessing the patients use,
    understanding and adherence to their medication
    regimen.
  • Medicines Therapy Assessment, which is a
    comprehensive clinical review of individual
    patients medication as part of a
    multidisciplinary team
  • Comprehensive Medicines Management, case based
    active management of changes and (future)
    collaborative prescribing

10
Compliance/Concordance/Adherence
  • Problems
  • - Perversity of human behaviour
  • - System related factors
  • - Therapy related factors
  • - Condition related factors
  • Solutions
  • - Patient education gains
  • - Medication adjustments
  • - Calendar packs, compliance packs
  • - Unit dose dispensing (bar codes)

11
Medicine Use Review and adherence support MUR
  • 1/ Ensuring that the patient understands
  • Why they are taking the prescribed medication
  • How it is going to benefit them
  • Side effects they may experience or are
    experiencing
  • 2/ Identifying any problems clinical or
    organizational and solving them
  • 3/ Ensuring that they take their medication
    correctly at the right time right quantity
  • 4/ Improve the health of your patient avoid
    hospitalisation (Gullery Love Report)

12
MUR Compliance support
  • Process -
  • a) Criteria for entry
  • Living in the community, chronic condition,
    three or more meds, hospital discharge, high risk
    communications, adherence problems already
    identified.
  • b) Identifying patients for MUR
  • Problems identified in the pharmacy, family
    concerns, doctor referral, Care Plus,
  • c) Assessment
  • Assemble patient, documents, medicines then
    interview (interpreter?)
  • d) Implementation
  • Medicines solutions, compliance aids e.g. trays,
    blister packs, own system?
  • Information/education, Yellow Card. Follow-up
    interview.
  • e) Report back follow up
  • Report to GP, add patient into calendar, follow
    up interviews (2/12months)
  • Electronic monitoring and health status
    reporting.

13
Case Study1. Poor understanding/beliefs
Family, education, packaging.
  • Pacific Island woman, middle-age.
  • Diabetic ,cardiovascular meds, illiterate poor
    eyesight
  • Metformin cartia- felodipine omeprazole-
    inhibace isosorbide- lipex-cromulux e/drops-
    paracetamol
  • Concerned about the amount of medication she was
    taking therefore did not take many.
  • Educated her and family on the medication and
    explained diabetes Showed her how to use eye
    drops
  • Had brand new meter ( from diabetes NZ ) didnt
    know reason
  • Compliance packaging / meter training on going

14
Case Study 2. physical impairment, own solutions
  • GP requested review on patient - nearly deaf
    almost blind- couldnt understand how he could be
    compliant
  • Daughter visits ever night for dinner (cooked by
    Dad!)
  • Daughter put tablets into different sized
    Tupperware containers based on dosing
  • Perfect system for him needed only education
  • Moved his Pholcodine Duphalac to different
    places in the lounge similar bottles, both
    sweet.
  • Cough mixture by whiskey bottle
  • Laxative on top of cabinet.

15
Case Study 3. Warfarin patient- wilful
non-compliance Interdisciplinary support
education weekly med. pack
  • Elderly gentleman-lives alone- cardiovascular
    meds including warfarin
  • Family concerned - Doesn't like meds, they were
    responsible for his wife's death therefore bad
    for you
  • Misses/Forgets meds frequently
  • MUR Education, Removed unwanted meds
  • Put on weekly trays ( family involved)
  • Yellow/Green card given photos of tabs on it
  • Anticoag.Clinic fax- doses appntmnt times
  • Dose appntmnt times confirmed with weekly
    medication tray pick up.

16
Case Study 4. Feeling awful
  • Felodipine 10mg mane, Betaloc 95 mane,
    simvastatin 40mg, isosorbide 60mg x2 mane, GTN
    spray prn, bendrofluazide 2.5mg mane, oxazepam
    10mg BD, Combivent inhaler QID.
  • Mrs K explained that she felt awful, so tired
    most of the time. By 10 oclock I just want to
    sleep, generally with a stonking headache. I
    feel bloated and awful inside and Im so short of
    breath and my nose is stuffy all of the time.
    Ive got aches pains all over its hard to get
    going in the morning, especially my leg muscles.
  • She worries about falling asleep at the wheel of
    her car and gets light headed at times especially
    when she rises. She presented a picture of
    desperation over how she felt and wanted to feel
    more like her old self get on with life.

17
  • a) Tiredness/fatigue
  • Metoprolol, felodipine and oxazepam at breakfast
    are a potent combination for fatigue and sleep.
  • b) Headache
  • Probably caused by 10mg of felodipine plus 2x
    60mg of isosorbide in the morning.
  • c) Shortness of breath ankle oedema
  • Are these symptoms of CHF, or chronic bronchitis
    related to asthma/COPD, and is the ankle oedema
    diuretic resistance swelling due to felodipine??
    Im working in the dark here.

18
  • d) Nasal stuffiness
  • This could be allergy related although the
    permanent nature of it leads me to suspect the
    peripheral dilation effect of felodipine. She
    tells me that nasal sprays have been ineffective.
  • e) Muscle aches and pains
  • Mrs K puts this down to taking Lipex.
    Myalgia/general malaise is a pretty common side
    effect which people complain of when they go onto
    simvastatin - ( felodipine competitive
    interaction liver enzyme substrate -CYP3A3/4)
    elevates the blood levels of both.
  • f) Walking/physical fitness (finally)
  • Mrs K likes to go walking for the feeling of
    wellbeing it gives her and of course it is to be
    encouraged. However because of feeling awful,
    SOB and pain in her toe joint, she now avoids
    walking. Restoring that ability would be a
    worthwhile objective, so possible options-

19
Where are we at?
  • NZ College of Pharmacists
  • Accreditation
  • Incentives
  • Barriers

20
Implementation- Opportunities
  • If we implement through the national PHO
    agreement we gain
  • Access to patient level information through
    enrolled populations
  • Linkages to other services such as CarePlus etc.,
    Chronic Disease Management and Health Promotion
  • Access to community engagement and community
    governance mechanisms
  • Synergy with the PHO Performance Management
    programme
  • Coordination and integration of services
  • i.e. Interdisciplinary care

21
Take home message
  • Compliance/ adherence support (MUR) works
  • GPs like it
  • Patients like it
  • Morbidity hospital admissions reduced
  • How can you reduce barriers?
  • Influence your peers, local pharmacists
  • and DHB/PHO staff

22
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