Transcript Title

New Zealand –
Can we live up to the ‘clean-green’
image?
Dr Rhiannon Braund
School of Pharmacy
University of Otago
New Zealand
Pharmaceutical Policies In NZ
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Strong focus on ‘access’ to medications (and
healthcare in general).
Individuals and families with lower income
have reduced costs to see a Dr or to collect
medications.
Pharmaceutical budget (~ $550 million p.a)
maintained by a government agency
(Pharmac) and they control the
pharmaceutical schedule.
Collecting Prescription Medications
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A prescriber writes a prescription for three months.
Historically this was issued as one month and two
repeats.
Patient paid a co-payment for first dispensing and
the additional two were at no cost, but could not
collect them until at least 20 days had passed.
This co-payment was either $15, $3, $2 or $0
depending on income and number of items collected
in a year.
What has changed?
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In 2004, introduction of ‘stat’ or ‘all-at-once’
dispensing.
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Save ~$60 million in dispensing/professional fees
~$24 million in wastage
Overall savings of ~$36 million p.a
Recently (2007) the patient co-payment was
reduced to $3 (NZD) for everyone.
↑ Access = ↑ Excess ?
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If the obvious answer is yes, then the next
question(s) are:
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How much?
At what cost? (Clinical, Financial and
Environmental)
Can we minimize this excess without
compromising access?
Identification of returns (Study 1)
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ODHB pay for the destruction of medications
returned to pharmacies
A random sample of boxes for destruction
were put aside for analysis
Almost 1300 kg returned in 9 month period
Analysed 160 kg (12%)
Braund et al 2007 NZFP
Conclusion (Study 1)
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All of the 20 most returned items = ‘stat’ but caution
as ‘stat’ was intended to increase access
One patient returned
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1198 paracetamol
1157 paracetamol/codeine
469 doxepin 25mg
362 warfarin tablets
7 100g tubes of hydrocortisone
Why are they being returned (Study 2)
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Previous overseas study found that those who
returned medications brought back average of 60%
of original prescription
The reasons included
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Bereavement
Expired medication
Person felt better
Doctor changed medication
Allergic reactions
Person did not want to take the drug
(26%)
(25%)
(11%)
(11%)
(8%)
(7%)
Cameron S. 1996 Can Med Assn J
Situation in Dunedin (Study 2)
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Pilot study
Two local pharmacies
Five week collection
Patients returning medication for disposal
were asked to complete a brief questionnaire
Braund et al 2008 NZFP
Reasons for unused medications
Braund et al 2008 NZFP
Conclusions (Study 2)
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Initiation of ‘trial’ prescribing
Quantity of ‘prn’ medications
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Amount vs period of supply
One patient = ~ $15 000 worth of medication
Media Interest
Situation in Hutt (Study 3)
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Approached by HVDHB to assist
Used our surveys
‘The main objective of this programme was
to minimise the potential risk of household
poisonings via safe and efficient methods of
disposing unused medications.’
Question about medication storage added
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31 community pharmacies
Four week collection period
1605 bags returned
653 completed questionnaires
Sample analysed (329 with 149
questionnaires)
All Qs were also analysed
Returns by quantity
Ranking Generic Name
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Diclofenac Sodium
Ibuprofen
Levodopa
Metformin HCl
Aspirin
Paracetamol Tablets
Prednisone
Codeine Phosphate
Simvastatin
Dextropropoxyphene HCl; Paracetamol
Calcium Carbonate
Omeprazole
Loperamide HCl
Amitriptyline
Warfarin Sodium
Metoclopramide HCl
Cilazapril
Naproxyn
Docusate
Metoprolol
Number
Returned
4462
4147
3521
3243
2839
2743
2480
2348
1727
1639
1618
1558
1489
1455
1366
1294
1098
1077
1017
872
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
Treatment Change
0
Figure 4. Number of reasons reported for returning medications (n=1254)
Others
Inconvenience/Difficulty
Following Instructions
Passed Expiry Date
Patient Deceased
Excess Quantity
Unsure Why prescribed
Resolved
Ineffective
Side Effects
Unclear Instructions
Number of reasons reported
Why was the medicine(s) not used?
‘Why was the medicine(s) not used?’
350
300
250
200
150
100
50
Conclusions (Study 3)
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Trial prescribing
‘prn’ medications
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Inhaler returns
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Pharmac change in June 2008
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Susan Judd
Storage and disposal survey (study 4)
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Online Survey (via NZ poison centre)
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Collecting medications
Collecting repeats
Storage
Disposal
Over a three month period 516 people
viewed the survey and it was completed by
452 individuals
Results
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62 % said that they currently had leftover or
unwanted medications at home.
48 % of people store their medications in the
kitchen, 29 % bathroom, 13 % bedroom
Disposal of unused
Response
Down the toilet
Down the sink
With household rubbish
Take it to the tip
Burn
Return to pharmacy
Give away
No answer
Medication Formulation Type
Liquid Tablets/
Ointments/
Capsules Creams
69
65
5
180
23
2
106
223
339
4
6
22
2
11
9
79
110
60
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11
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Number of Responses
Reasons for unused medication
350
300
250
200
150
100
50
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Number of Responses
Why do you keep unused medications
250
200
150
100
50
0
Where to from here?
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In 2009, will start analysis of different water
systems to determine if trace levels of
pharmaceuticals
Also ‘life of a prescription’ study. This will
investigate what types of medications are not
collected, used etc
Acknowledgements
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Community Pharmacists
Undergraduate Pharmacy Students
NZPERF
NZ National Poison Centre