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Pharmaceutical care in Europe Latest developments


Pharmaceutical care in Europe Latest developments Dr. J.W.Foppe van Mil Community Pharmacist Professional Secretary PCNE Question 1 How far are we in implementing ... – PowerPoint PPT presentation

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Title: Pharmaceutical care in Europe Latest developments

Pharmaceutical care in Europe Latest developments
  • Dr. J.W.Foppe van Mil
  • Community Pharmacist
  • Professional Secretary PCNE

(No Transcript)
Question 1
  • How far are we in implementing pharmaceutical
    care by pharmacists in Europe? What are the

Question 2
  • Have we managed to prove in Europe that
    pharmaceutical care by pharmacist improves the
    patients outcomes (ECHO model)?
  • Clinical outcomes
  • Economical outcomes
  • Humanistic outcomes
  • quality of life the outcome that matters for
    the patient
  • satisfaction

  • How to assess the status of pharmaceutical care
  • Latest literature
  • Status disease-wise
  • What still needs to be done
  • Conclusion

How to assess the status of pharmaceutical care
  • Literature review
  • Talk to colleagues, be part of PCNE, ESCP and
  • Listen to many speakers at conferences
  • Ask questions
  • Do we then get the answers?

Challenges especially in Europe
  • Varying health care systems
  • Different roles of pharmacists
  • Varying definitions of what constitutes
    pharmaceutical care
  • Different terminologies
  • Inaccessible languages
  • Example Farmacia hospitalaria órgano oficial
    de expresión científica de la Sociedad Española
    de Farmacia Hospitalaria in Spanish)
  • Many national and even local pharmacy practice
    publications, that are not in Medline or any
    other database

Recent Issues
  • Implementation barriers
  • Several papers on ethics and legislation
  • Role of pharmacists vs staff
  • Relationship with other health-care professionals
    and with the patient (UK)
  • Adapting and working with instruments e.g. Beers
    Criteria for medication reviews

Beers criteria, developments
  • Beers criteria are an instrument to conduct a
    comprehensive medication review in the elderly,
    first published in the US in 1991
  • Expert panel identified 19 drugs that should
    generally be avoided and 11 doses, frequencies,
    or durations of use of specific drugs that
    generally should not be exceeded.
  • Example certain medicines should not be
    prescribed to the elderly e.g. short acting
    benzodiazepines, long acting barbiturates etc.
  • Instrument not appropriate for use in European
    countries because of the differences in national
    drug formularies and prescribing practices and
  • Effectiveness of instrument depends on its
    setting must be adapted to time, population,
    national drug selections.

Beers criteria, adaptations
  • Update by Beers et al in 1997 (for US)
  • Update by Flick et al in 2003 (for US)
  • 2006 Language/culture and medicine adaptation for
    Portugal (de Olivieira) and France (Larochet)
  • 2007 Language/culture and medicine adaptations
    being done for Germany, Poland and the
  • But . adaptations make international comparisons
    more difficult.

  • van Mil JWF. Atención Farmacéutica en Farmacia
    Comunitaria en Europa, retos y barreras
    Pharmaceutical Care in Community Pharmacy in
    Europe, challenges and barriers. Pharm Care Esp
  • Berenguer B, La Casa C, de la Matta MJ,
    Martin-Calero MJ. Pharmaceutical care past,
    present and future. Curr Pharm Des
  • Martin-Calero MJ, Machuca M, Murillo MD, Cansino
    J, Gastelurrutia MA, Faus MJ. Structural process
    and implementation programs of pharmaceutical
    care in different countries. Curr Pharm Des
  • van Mil JWF, Schulz M. A review of Pharmaceutical
    Care in Community Pharmacy in Europe. Harvard
    Health Policy Review 20067 (1)155-168

Annals series
  • Series of articles on Community Pharmacy in the
    world in Annals of Pharmacotherapy
  • Ongoing series coordinated by people in US,
    Europe and Australia
  • Publications from Eastern Europe and Asia still

Focus of Annals publications(1)
Finland Asthma study implementation Improving medication in the elderly
Netherlands Appropriateness of medication Drug related problems Diabetes/Asthma Counselling/Pseudo customers
Denmark Self-care and OTC Implementation research (with Spain and Portugal)
Focus of Annals publications(2)
Germany Asthma, Diabetes The Family Pharmacy project Pseudo customer/ counselling quality
Switzerland Local Quality circles (FTOs in NL) Health promotion activities (Diabetes, smoking cessation)
Sweden Self care referral PhC in the elderly and their DRPs
Focus of Annals publications(3)
United Kingdom/ England Medicine use reviews Smoking cessation support Methadone programs Pharmacist prescribing
Portugal Methadone needle exchange Generic disease management programs

Activities in the Netherlands
  • Individualised pharmaceutical care
  • 1. Medication surveillance and coaching.
  • 2. Medication analysis based on selections with
  • 3. Disease oriented projects
  • 4. Special instructions at therapy initiation
  • 5. Home care and OTC counselling
  • Supporting activities
  • Seamless care data transfer
  • Pharmacotherapy discussions with physicians

Disease oriented Pharmaceutical Care
  • Germany Community pharmacy-based pharmaceutical
    care for asthma patients Positive impact on
    humanistic and clinical outcomes. Mangiapane et
    al. Ann.Pharmacother. (2005).
  • Belgium Medication use and disease control of
    asthmatic patients in Flanders a cross-sectional
    community pharmacy study No intervention yet,
    test of Instrument. Mehuys et al. Respir.Med
  • Review More favourable PC outcomes were
    associated with use of all elements of PC,
    independent pharmacies, pharmacist certification,
    a detailed PC protocol, targeting patients with
    uncontrolled asthma, and a practice system
    facilitating innovation PC. McLean et al. Ann
    Pharmacother (2005)
  • Other positive data from Denmark (Herborg), Spain
    (Andrès), Malta (Cordina), N. Ireland(Cordina)
    and Netherlands (van Mil, Stuurman-Bieze)

  • Review Sensitivity of Patient Outcomes to
    Pharmacist Interventions. Part I Systematic
    Review and Meta-Analysis in Diabetes Management.
    General conclusion HbA1C levels are sensitive to
    pharmacist interventions. Machado et al.
    Ann.Pharmacother. (2007, not only Europe).
  • Switzerland Pharmaceutical care model for
    patients with type 2 diabetes integration of the
    community pharmacist into the diabetes team-a
    pilot study Reduction in HbA1c and cholesterol
    values. Wermeille et al. Pharm.World Sci (2004).
  • Belgium Medication use and disease management of
    type 2 diabetic flemish patients Pharmacist
    should take a role. Mehuys et al. Pharm World Sci
  • Norway Diabetes care in pharmacy. 30 Of
    pharmacist involved in diabetes care. Kjome et
    al. PWS (2007 on-line first.)

  • Turkey Effect of pharmacist-led patient
    education on adherence to tuberculosis treatment
    Improved adherence. Clark et al. Am.J Health
    Syst.Pharm. ( 2007)

  • Spain Pharmaceutical care in hiperlipemic drug
    patients. Decrease in the mean values of total
    cholesterol and triglycerides. Cardo Prats et
    al. Pharm Care Esp (2001).
  • Germany Pharmaceutical care in patients with
    disturbed lipaemic patterns Improved lipid
    profiles, improved compliance. Birnbaum et al.
    Pharm.Ztg. (2003).
  • Belgium Effect of intervention through a
    pharmaceutical care program on patient adherence
    with prescribed once-daily atorvastatin improved
    compliance and persistence. Vrijens et al.
    Pharmacoepidemiol.Drug Saf 15 (2)115-121, 2006.

Parkinsons disease
  • UK Pilot in PhC in community pharmacy of
    Parkinson patients Increased compliance. Minors
    et al. Pharm J (2007)
  • Scotland Effect of educational intervention on
    medication timing in Parkinson's disease a
    randomized controlled trial Improved timing
    adherence. Grosset KA et al. BMC Neurol. (2007).

  • Denmark Pharmaceutical Care in borderline
    Migraine. No clear impact. Soendergaard et al.
    Scand J Prom Health Care (2006).

Congestive Heart Failure (CHF)
  • Spain Post discharge Pharmaceutical care in
    heart failure Reductions in readmissions and
    hospital stay. Lopez Cabezas et al. Farm.Hosp
  • UK Medicines management in Coronary Heart
    Failure. But no positive impact. Holland et al,
    (BMJ 2007).

Over The Counter
  • In the past there have been many studies in the
    past in the field of Over The Counter medication.
  • These studies show a positive impact of
    counselling on behaviour and satisfaction
  • In many countries OTC counselling has been
    implemented in practice, and structured
  • But Counselling is not pharmaceutical care!
    and there has been no follow-up
  • Impact of PhC on outcomes in OTC medication
    remains an important field for study!

Comprehensive Drug Use Review (1)
  • Community
  • Netherlands FTOs Latest report of DGV indicates
    808 pharmacotherapy discussion groups in NL, of
    which more than 50 function optimally. DGV
    report 2007
  • UK Home-based medication review in a high risk
    elderly population in primary care--the POLYMED
    randomised controlled trial Had only impact on
    number of medicines (economics?). Lenaghan et al.
    Age Ageing 2007.
  • UK Review in chain pharmacies. Study from
    University of Nottingham to be published.
  • Poland Polypharmacy and potential
    inappropriateness of pharmacological treatment
    among community-dwelling elderly patients it is
    a frequent problem in Poland, and a project has
    been started. Rajska-Neumann et al. Arch
    Gerontol.Geriatr. (Suppl 2007).

Comprehensive Drug Use Review (2)
  • Hospital
  • France Implementation of a Canadian
    Pharmaceutical Care model in a French paediatric
    department. Many DRPs detected and solved. Proth
    Labarthe et al. Arch Pediatr (2007).
  • N. Ireland Preventing hospital readmissions by
    medicines management Rate of, and time to
    readmission decreased. Scullin et al. J Eval Clin
    Pract (2007)
  • Belgium Improving appropriateness of prescribing
    in elderly people admitted and discharged in
    hospital, pilot. Successful improved
    appropriateness. Spinewine et al. Ann
    Pharmacother (2006) J Am Geriatr Soc (2007).

Comprehensive Drug Use Review (3)
  • Nursing homes
  • UK Pilot of transfer Fleetwood model for Drug
    Use Evaluations in nursing homes from the USA.
    Barrier is seamless access to medical data. Huges
    C et al. Pharm World Sci (2007)
  • Netherlands A study of medication reviews to
    identify drug-related problems of polypharmacy
    patients in the Dutch nursing home setting 3,5
    problems per patient found, 1.7 problems solved
    at follow up. Finkers et al. J Clin Pharm Ther

  • Non-significant findings are usually not
  • In case of pharmacist interventions, however,
    non-significant findings are sometimes reported
    in especially medical journals (sic!)
  • Magnitude of the effects of pharmaceutical care
    interventions also depends on the current state
    of healthcare impact of a diabetes intervention
    will potentially be largest in countries where
    the diabetes patients are badly regulated.

Conclusion (1)
  • Disease oriented pharmaceutical care does have a
    proven effect on intermediate outcomes like
    adherence and (of course) patient satisfaction.
  • Comprehensive medication review has an impact on
    the appropriateness of the pharmacotherapy, but
    real effects on the ECHO outcomes have not yet
    been firmly established.
  • More insight into the real implementation of
    pharmaceutical care in Europe is urgently needed

  • How to assess the status of pharmaceutical care
  • Latest literature
  • Status disease-wise
  • Status of the implementation
  • What still needs to be done

  • My personal impression is that pharmacists, and
    especially their organisations in most countries
    are still too busy with MMs (management and
  • Pharmacists and their associations should realise
    that the value of the profession to society can
    not be measured in Euros earned, but in the
    impact they have on the outcomes that matter to
    the patient.
  • The question if pharmacists must provide
    pharmaceutical care lies behind us yes we must
    please start