FIP 2008: How pharmacists in the future can improve therapeutic outcomes
A symposium on pharmacy practice at present and in the future wasorganised by the board of pharmaceutical practice, at the 2008 WorldCongress of Pharmacy and Pharmaceutical Sciences. Pamela Mason reports
A symposium on pharmacy practice at present and in the future was organised by the board of pharmaceutical practice, at the 2008 World Congress of Pharmacy and Pharmaceutical Sciences. Pamela Mason reports
Is it true to say “the pharmacy is dead, long live the pharmacist”? That question was put to the symposium in a presentation given by Thony Björk, vice-president, international affairs, Apoteket AB, Sweden.
“The answer is yes, if you only see pharmacy as a point where you pick up your medicines. But it is not true if you listen to the profession’s ambitions to deliver additional services to the patient. The truth probably lies somewhere in between,” he said.
Changing healthcare systems have implications for pharmacy practice, Mr Björk said. Although there is no doubt that a pharmacist is needed in pharmacies, the exclusive right to own a pharmacy is under pressure and pharmacy is not the only place for obtaining medicines.
“We need to continue everything we are doing now — giving advice on medicines, self-care, health promotion — but with a greater focus on patients and customer need.” The pharmacy business needs to be further developed in the direction of services to patients and consumers.
The pharmacist in the future will make an increasing contribution to effective drug therapy outcomes. There will also be increased demand for pharmacists in the healthcare sector, not just in pharmacies.
But pharmacists need to gain confidence in the healthcare arena and with other professionals.
Co-operation with other healthcare professionals is essential, he added. “The goal must be whenever and wherever medicines are discussed, a pharmacist must be wanted and present.”
Closing the efficacy-effectiveness gap
“The present healthcare system is not safe, effective or efficient. Resolution of this contradiction requires different healthcare practice with new roles for patients, doctors and pharmacists. Medical care has advanced at an enormous rate in the past 50 years and patient expectations have also changed.
“However, healthcare delivery is poorly organised and fails to deliver potential treatment benefits. There is not just a gap between efficacy and effectiveness, but a chasm.”
Explaining further, Professor Bugnon said that evidence from clinical trials demonstrates the efficacy of many therapies (eg, antihypertensive medicines reduce cardiovascular mortality and morbidity), but evidence of effectiveness in the real world conditions of routine care is lacking because of a lack of research.
He went on to outline the differences between efficacy studies and effectiveness studies. Efficacy studies are characterised by highly selected patients with no health problems other than the condition being investigated. They take place in strict settings with medical follow-up and have low drop-out rates.
Effectiveness in routine care is studied in a different context, where patients are heterogeneous, with multiple illnesses, non-adherent to treatment and the drop-out rate is high. Unlike the randomised controlled trial of efficacy studies, effectiveness studies evaluate individualised treatment in the context of an individualised therapeutic relationship.
Professor Bugnon then considered how pharmacists can improve the effectiveness of drugs used by patients — ie, how they can reduce the gap between efficacy and effectiveness. To begin with, it is important to understand and break down both patient and healthcare professional barriers to effective drug treatment.
Patient-related barriers to effective drug treatment include limitations on access to healthcare (eg, health insurance, drugs and healthcare providers), increased susceptibility to drug related problems with increasing age and chronic illness and poor adherence to therapy.
Healthcare professional barriers to effective drug treatment include unfamiliarity or disagreement with evidencebased guidelines, lack of evidence of benefit for specific patient groups, overestimation of patient adherence, lack of communication skills, lack of confidence between patients and providers, lack of time, lack of skills and lack of follow-up.
To improve the effectiveness of drugs used by patients demands an improvement in, among other things, the effectiveness of pharmacy services. In other words, he said, there is also an efficacy-effectiveness gap in pharmaceutical services.
There is also a need for better pharmacy practice research because there is a need to be sure that pharmacy services improve healthcare. In pharmacy services research, for example, it is not unusual to find that economic and therapeutic outcomes are not measured.
Professor Bugnon went on describe an adherence intervention programme for hypertensive patients conducted by community pharmacists in a Swiss university medical outpatient clinic. The programme involved 89 patients, most of whom were taking at least three medicines.
Follow-up conducted with electronic pill boxes indicated that median systolic blood pressure fell by 15mmHg and median diastolic blood pressure by 10mmHg.
These results were good enough to conduct a controlled trial in more community pharmacies. The subsequent randomised controlled trial of 12 months’ duration included 34 patients in the usual care group and 34 patients in the intervention group.
An increased odds of achieving the target blood pressure at four and 12 months was found in the intervention group. However, only 13 pharmacists participated.
The next step was to implement the programme nationally, with remuneration and an education programme for the pharmacists. In this case, after 10 months, only 25 (out of a possible 600) Swiss community pharmacists, eight physicians and four patients participated.
When pharmacy participation is so low, it is impossible to demonstrate the added value of pharmacists, he said.
In conclusion, Professor Bugnon emphasised that pharmacy practice research has to improve with interventions evaluated according to both efficacy and effectiveness. To guarantee the effectiveness of pharmacy services means giving priority to services with practical significance in terms of public health and professional values (eg, drug-related problems and adherence).
It is also important to determine a precise strategy for dissemination, implementation and monitoring of the service, based on efficacy-effectiveness outcomes research. “This will help to ensure that more pharmacists become evidence-based pharmacists,” he said.
Added value of the pharmacist
“The goals of pharmacists are remarkably similar round the world — ie, to achieve individualised therapeutic outcomes, keep patients safe and make medicines affordable and accessible.”
Numerous community pharmacy initiatives globally have shown that pharmacist coaching to instruct patients in self-management of chronic disease leads to significant improvements in clinical outcomes and reduced healthcare costs.
Pharmacists have been shown to be particularly successful in high risk patients and during transfer of care from one healthcare setting to another. US clinical pharmacy service practice models in Kaiser Permanente and the US veterans administration clinics have demonstrated the added value of pharmacists in resolving drug related problems and managing medication costs.
This helps to reduce health insurance premiums and makes healthcare affordable for more people, he said.
Dr Helling went on to describe a Kaiser Permanente clinical pharmacy anticoagulant service. This is a centralised telepharmacy model that employs 17 clinical pharmacists and three pharmacy technicians to provide services to over 7,200 patients. Services include
- warfarin management
- outpatient management of deep vein thrombosis
- bridge therapy for surgical procedures
- management of excessive coagulation
Results have been dramatic in terms of improved international normalised ratio (INR) control and decreased complications. Clinical pharmacy maintained patients are 40 per cent less likely to suffer any bleeding, clotting or fatal complication. These reduced complications are due to improved therapeutic INR management, Dr Helling said.
Going on to describe the Kaiser Permanente clinical pharmacy cardiac risk service, again a centralised telepharmacy model with a computerised tracking system, Dr Helling said that early clinical pharmacy intervention (ie, less than 90 days post-cardiovascular event) delivered an 89 per cent reduction in all-cause mortality and an 88 per cent reduction in cardiac-related mortality with US$3m saved each year due to reduced hospital admissions.
Compared with the national average for healthcare management organisations, the Kaiser Permanente clinical pharmacy service is associated with 135 fewer deaths, 234.4 fewer cardiac deaths and better control of cholesterol, blood pressure and diabetes.
Dr Helling also highlighted the opportunities for pharmacists in managing the high costs of future medicines. These include
- influencing appropriate patient selection
- determination of therapeutic equivalence
- calculation of appropriate dosage and duration of treatment
- monitoring of patient adherence, laboratory tests and prescription repeat frequency
- establishing clinical guidelines for use
- working collaboratively with clinicians
Providing medicines plus care
However, to make the paradigm shift to “the pill plus the care surrounding it” is a challenge, he added.
Dr Møldrup went on to describe the healthcare environment of the future. First, the modern patient is increasingly a consumer, not a patient. Consumers want quick, powerful, easy tools to help them to be healthy and happy, and in some cases, this tool might be a pharmaceutical product.
Thus, in the 2004–05 European social survey, 49 per cent of the surveyed population showed approval or strong approval for use of medicines in healthy people to improve memory while equivalent figures for approval or strong approval for use of medicines to reduce hair loss were 37 per cent, for use of medicines to improve sex life, 34 per cent, to feel happier 26 per cent and to lose weight 17 per cent.
Continuing to describe the healthcare environment of the future, Dr Møldrup said that the human genome will increasingly focus doctors on individual patient response to treatment. Not only will pharmacotherapy need to be individualised but also the information that goes with it.
Another issue is that health care payers will increasingly look for treatment that produces results — in short, no cure, no pay. The UK is already trying to put this into effect, he said.
But it will not be good news for the pharmaceutical industry, which already faces pressures such as the growth in generics, the lack of new innovations and patents running out. Although sales of medicines are increasing, this is mainly due to an increased population of older people.
However, the industry does have an alternative future, even with no or few new products, and that is to deliver care and services around its existing products. So, an antidiabetic drug could be marketed together with a blood glucose meter and lifestyle advice.
The drug plus the additional service would equate to a brand new product, he said. This “new product” can be tested more easily in a care setting than the medication alone. The medicine could then be taken off the market and sold only as part of a package. It would then be easier for the industry to compete with generics and analogues.
Concluding, Dr Møldrup asked where pharmacy would fit into this future. The patient would still visit the doctor and the doctor would still write prescriptions but instead of handing out a pill, the pharmacist would hand out the “pill-plus service” package.
It was the pharmacist who would do this because the industry is not allowed to interact directly with the patient. Remuneration for providing the whole package would come from the industry and pharmacists would provide not only evidence-based medicine but evidence-based care.
However, that poses the question as to whether pharmacists will want to get into bed with the industry, Dr Møldrup concluded.
Reports from the 68th World Congress of Pharmacy and Pharmaceutical Sciences
Citation: The Pharmaceutical Journal URI: 10038102
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