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Pharmacy-based asthma services in Denmark Lotte Fonnesbæk Danish College of Pharmacy Practice Hillerød, Denmark Health Promotion Bruxelles 00 Pharmaceutical Care - A system approach Continuous quality improvement function aimed at the drug use system Focuses on inadequate managing of drug therapy identify and resolve drug related problems The purpose is to ensure optimal QOL (clinical and humanistic outcomes) in a cost-effective way Hypothesis: Working with isolated factors is an inadequate approach to preventing drug related morbidities (therapeutic failure and adverse events) Health Promotion Bruxelles 00 Objective To evaluate if quality improvement of drug therapy by use of therapeutic outcomes monitoring can improve clinical and psycho-social outcomes for asthma patients and influence the medication use and use of health care resources Health Promotion Bruxelles 00 The Danish TOM model Equal emphasis on Patient perspectives, e.g., coping, control and empowerment Professional perspective, e.g., non-compliance, lack of knowledge and therapeutic problems Health Promotion Bruxelles 00 TOM steps 1. Establishing the patient relation 2. Collecting data on patient preferences and medication history 3. Identifying and analyzing drugrelated problems 4. Negotiating and defining targets 5. Choosing individual intervention and monitoring plan 6. Implementing plan and following up 7. Documenting the process and giving feed back Health Promotion Bruxelles 00 TOM sub-services Check of Peak-flow, inhaler technique, asthma symptoms and patient perceived problems Assessment of the total drug therapy Assessment and monitoring of drug use and compliance Referral to GP Counselling on problem solving in everyday life Education on asthma, medication, and self management – Instruction in inhaler technique – Instruction in self monitoring: Peak-flow measurement and use of diary – Instruction in self regulation – Instruction in attacks management Health Promotion Bruxelles 00 Combined evaluation strategy Formative evaluation and pilot tests Effect evaluation Process- and participant evaluation Health economical analysis Qualitative interview study Health Promotion Bruxelles 00 Participants in the controlled trial 16 study pharmacies 15 control pharmacies 139 physicians 264 study patients (drop-out-rate 20,8%) 236 control patients (drop-out-rate 13,6%) Health Promotion Bruxelles 00 Pharmacy activity The average pharmacy has in the period September 1994 - July 1995 had: 15.4 patients/month 11.2 pharmacist consultations/month 2.0 telephone consultations/month 10.9 reports to the GPs/month Time consumption: pharmacist consultations telephone consultations reports administration, misc. 40.5 minutes/consultation 9.5 minutes/consultation 34 minutes/report 6 hours/month Health Promotion Bruxelles 00 The Danish TOM project Effects on outcomes and proces Improvement in intervention group related to controls after 12 months Outcomes Asthma symptom status Asthma morbidity + 12% 3.2 days per patient saved per year Quality of life (global) Asthma related QoL Satisfaction with health care + 34% + 12% no change Proces Clinical and psycho-social effects Peak-flow of the day Knowledge Inhalation technique Drug use Percentage of steroid users Short-acting B2-agonist, DDD’s Use of health care GP contacts Other contacts no change + 27% + 55% + 15% - 21% (n.s.) increase decrease Patient perceived benefits Asthma symptoms QoL, coping, control Drug use Knowledge Co-operation with pharmacist Unchanged GP relation 44-61% 40-60% 64-77% 82-92% 75% 79% Health Promotion Bruxelles 00 GP satisfaction Programme quality high Pharmacist competent partner Patient relationship no worse Unclear responsibility Problems with quality 85% 70% 93% 14% <4% General attitudes to the new role are still sceptic Health Promotion Bruxelles 00 Comments from the general practitioners “The pharmacy staff has acted loyally and conscientiously. The patients became better at controlling and handling their disease. All patients were happy for this extra help.” “In a somewhat funny way the pharmacy had success with having the patient take the steroid treatment I had tried to make her take for years.” Health Promotion Bruxelles 00 Comments from the general practitioners “My attitude still is that it ought to be the patient’s GP who carries out any drug therapy - monitoring etc. It is not the role of the pharmacy”. “It should not be the pharmacy’s job, it belongs naturally under the general practitioner or a lung specialist. Too many cooks spoil the broth.” Health Promotion Bruxelles 00 Comments from the general practitioners “Keep on doing it! The project was a very positive experience. There is a great potential in increased collaboration between the pharmacy and the primary sector. I hope that the consultant role of the pharmacist can be extended to i.e. nursing homes.” Health Promotion Bruxelles 00 Conclusion The project has demonstrated: 1. The Danish community pharmacy can deliver a TOMprogramme – which improves outcomes of treatment for asthma patients – with a positive health economical balance and – in a positive collaboration with general practitioners 2. Sensitive outcome measures for pharmaceutical care need to be developed 3. Combined evaluation strategies are needed Health Promotion Bruxelles 00 The development of asthma services 1. European guidelines – EuroPharm Forum: Pharmacy-based asthma services Asthma services within the four main areas of GPP The guidelines focus three levels of pharmacy-based asthma services 2. Further development of the Danish model for pharmaceutical care at the counter 3. Asthma-allergy counsellor – An education developed in collaboration with the Astma Allergy Association Health Promotion Bruxelles 00 The development of asthma services 4. Creation of priced asthma services – To be introduced in the campaign year 2001 of the Danish Pharmaceutical Association 5. Constructing a concept for a specialist pharmacy – An “Asthma-allergy pharmacy” has been suggested – Development of a certification system Health Promotion Bruxelles 00 Pharmaceutical care models Basic models – Group specific programmes – – – All pharmacies: Dealing with all types of drugs. Offered to all patients Example: Pharmaceutical care at the counter Specific pharmacies according to local health needs Dealing with all types of drugs Offered to population groups with special needs Example: Elderly, child-families, discharged patients etc. Disease specific programmes – – – Specific pharmacies according to local health needs Dealing primarily with disease specific drugs Offered to patients with diseases where prevention of drug related morbidity is particularly promising Example: Therapeutic outcomes monitoring (TOM) offered to asthma patients, diabetes patiens etc. Health Promotion Bruxelles 00