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

Martine RuggliPharmacist FPHpharmaSuisseSwitzerland

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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

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•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

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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 ?

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 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

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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?

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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