FIP Congress 2006
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Public demand for innovation places a considerable
burden on health care providers. The four symposia of the congress's
pharmacy practice programme examined innovations in patient treatment,
innovative health care delivery, using innovations to improve patient
safety (reported by Pamela Mason) and innovations in learning and
education (reported by Steven Kayne) and described possible solutions
that are being developed
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 The World Congress of Pharmacy and Pharmaceutical Sciences,
the 66th International FIP Congress, was organised by the International
Pharmaceutical Federation in association with the Federal
Council of Pharmacy of Brazil.
It took place in Salvador da Bahia from August 26 to 31, 2006
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Health care delivery at patients' homes is a unique and innovative opportunity
Home health care represents a unique opportunity for pharmacists, said
Tim Chen, of the faculty of pharmacy at the University of Sydney, Australia,
when he spoke at a session that examined new and future changes in health
care delivery. He discussed the home as the centre for health care delivery
and the pharmacist’s role in home health care.
Home health care refers to the provision of complex pharmaceutical products
(eg, home infusion therapy, home dialysis), clinical assessment and monitoring
in the patient’s home, he explained. Health care at home can free
hospital beds, reduce health care costs, shorten patient recovery times
and remove the risk of hospital-acquired infections.
However, the standard
of care should not be compromised, and it is important to be sure that
the hospital service can be appropriately delivered at home.
In terms of opportunities for pharmacists, in addition to the supply
of medicines (eg, oral medicines, infusion therapy, parenteral and enteral
nutrition) and clinical monitoring services, pharmacists can provide
training and education to patients and carers on the use of medicines
and devices.
The boundaries between hospitals and community care settings
are disappearing, but this increases the challenge to provide seamless
care, he added. Pharmacists can play a key role in helping to ensure
the effective transfer of patient information through application of
robust documentation systems. Multidisciplinary collaboration is essential
and the expectations on the “seven star pharmacist” as care
giver, decision maker, communicator, leader, manager, life-long learner
and teacher are high, he said.
Dr Chen went on to describe examples of home health care, beginning with
Australia’s hospital in the home (HITH) programme, which was developed
in the mid 1990s. In this, programme hospital care is provided in the
patient’s own home, but patients are regarded as hospital inpatients,
receiving the same treatment and they are also seen by a doctor or nurse
at least once a day. Types of conditions managed include chemotherapy,
cellulitis, respiratory conditions, and kidney or urinary infections.
Evaluation
of this programme has shown that it is safe, effective, cost effective
and cheaper than non-HITH care. Length of stay for full HITH
care is less than for non-HITH) care while length of stay for mixed HITH
(mixed with hospital care) is greater than for non-HITH care, although
cost does not differ.
Mentioning a recent Cochrane review, “Hospital at home versus inpatient
hospital care”, Dr Chen said that this has reignited the debate
on the efficacy of this method of care delivery. This meta-analysis of
22 studies concluded there is no difference in outcomes and no cost savings
(but with tendencies in a positive direction towards HITH care), though
patient satisfaction is higher with HITH care.
Home medicines review (HMR) was the second example of home health care
that Dr Chen discussed. HMR represents a good example of how pharmacists
can actively contribute to home health care as part of a multidisciplinary
team. Australian pharmacists are paid for this service, he said. HMR
involves GP referral to the patient’s preferred community pharmacist,
upon which the pharmacist visits the patient at home and reviews their
medication.
The pharmacist then provides the GP with an HMR report and
the GP and patient agree on a medication management plan. Since October
2001, more than 100,000 HMRs have been undertaken by pharmacists, seen
by GPs and funded by government with a constant growth in uptake of
the service, he added. Patients are mostly older people (aged 65-85 years). Medicines distribution
Martin Schulz, head of the centre for drug information and pharmacy
practice at ABDA, Berlin, Germany, focused on the dispensing costs for
pharmaceuticals
delivered through different supply channels. Medicines are traditionally
distributed from the manufacturer through wholesalers to the pharmacy
and then to the patient who presents a prescription for the medicine,
he said.
However, the traditional supply chain is being challenged directly
by changes in government policies and indirectly as a result of the changing
commercial strategies of the pharmaceutical industry, wholesalers and
import companies, he added.
He went on highlight the range of alternative routes that now exclude
wholesalers or pharmacies, or both. Retailers other than pharmacies can
sell several medicines and devices. For example, home care or disease
management services include supply of devices and medicines for the treatment
of long-term conditions such as diabetes, asthma, cancer, HIV/AIDS and
hypertension.
The more widespread application of pharmacogenomics may
further change the supply chain for pharmaceuticals. Switches of products
from prescription-only to OTC status will also have an influence, he
added.
Turning his attention to parallel or cross border trading for medicines
and mail order, he said that one company in the middle of Europe has
announced its intention to provide 600,000 primary care patients with
a unit dose/blister service. Although its system is suitable only for
400 different solid, oral dosage forms of drugs, the company has said
that it aims to gain 10 million patients with its service in the coming
years. An independent analysis of this service indicates that potential
savings for the insurance fund would be €0.35 per blister but expected
additional costs to the company would be €2.65 per blister, said Professor
Schulz.
Mail order pharmacy, smart card technology and electronic prescriptions
will also have an impact on supply chains. Reporting on a survey of 20
mail order pharmacies, Professor Schulz said that nine were associated
with “good” performance results (ie, ordering/delivery service,
counselling by telephone, home page information), one was “satisfactory” and
10 were “poor”. Mail order
is less expensive overall and cheaper for patients. However, it is more
expensive for the health plan because the loss of co-payment is greater
than savings in ingredient costs and dispensing fees, he added.
In his opinion, these challenges mean that pharmacists in the future
will need to develop a strong strategy and an innovative business model
with more than one supply chain. He went on to describe an emerging model
of “family pharmacies” in Germany. Patients choose their “family
pharmacy” from a list of participating community pharmacies and
sign up for one year. All medicines, devices and supplements are recorded
on the pharmacy computer and provided by this pharmacy with facilities
for home delivery and online ordering.
The service includes counselling
on the use of medicines, regular checks for contraindications, interactions
and compliance, medication review and quarterly medication reports for
both patient and doctor with remuneration for advanced services.
Up to June 2006, 87 per cent of community pharmacies in Germany had entered
into a contract with the GP association and health insurance company
(Barmer) and had been trained to provide such a service. “This
system of family pharmacies represents one promising way forward for
pharmacists to maintain and control the quality of medicines and their
availability to patients — in other words, drugs plus personal
service.”
In another presentation, Per Troein, vice-president, strategic alliances,
at IMS Health, said that new supply channels such as mail order, home
care, specialist pharmacies and hospital dispensing direct to the patient
are in most cases driven by financial interest and are only successful
if they demonstrate added value. Potential benefits of these new channels
include improved patient information, in-depth knowledge of specialty
drugs, nursing care, patient convenience and compliance programmes.
However,
many people prefer to speak to a human being they trust, ie, their pharmacist,
he said. But the standards are increasing, with the need to check for
interactions and patient compliance and improve patient convenience in
the form of home
delivery.
“Community pharmacies are at risk of [not being able to dispense]
very expensive drugs and at the same time the loss of patents and growth
of
generics will reduce prices of other drugs. These financial risks can
partly be managed by systems switches from dispensing fees to fees based
on service,” he concluded. Managing innovation
Steve Hudson: innovation helps health care to evolve |
Steve Hudson, of the University of Strathclyde, Glasgow, UK, speaking
on the value of practice research in helping to manage innovation,
said that innovation is an integral part of service delivery and helps
health care to evolve. However, innovations need time to be shown to
be safer as well as more effective. Introduction of new treatments
or new uses for existing treatments requires the introduction of clinical
service innovations. Although new treatments or new uses are evaluated
before introduction, clinical service innovations usually need to be
put in place before they can be formally evaluated, with practice research
rarely preceding their
introduction.
Turning to the role of practice research, Professor Hudson said that
it helps to demonstrate the impact of treatment change. This then leads
to the incorporation of the drug change within clinical services. Teamwork
accommodates the changes within general principles of best practice with
the result that best practice evolves in response to the changes. Research
therefore widens understanding of best practice in response to patients’ needs.
Practice research also informs continuous improvement and helps to validate
best practice while impacting reproducibility of services.
He went on to provide some examples of research programmes designed at
the University of Strathclyde to demonstrate innovations in pharmaceutical
care in three areas, namely, cancer chemotherapy, rheumatoid arthritis
and diabetes care. Pharmaceutical care plans to record care issues have
been developed for all three conditions. Generation of a database of
care issues allows profiling of current services provided by clinical
pharmacy specialists in different settings with extension of the care
plan concept to community pharmacy. Databases of care issues also help
to quantify patient adherence to treatment guidelines, standardise the
use of new treatments and allow the collection of aggregate data on patient
characteristics, including drug histories and co-morbidity, adverse drug
reactions and appropriateness of therapy.
Research is helping to build
a Scottish consensus on models of pharmaceutical care, identify patients’ needs
and expectations and define pharmacists’ continuing education needs.
The research is also expected to improve teamwork between patients and
other healthcare professionals. The need for a joint agenda is currently
being formalised with partnership arrangements between schools of pharmacy
and health service organisations.
“It is my belief that the future
of service developments in pharmacy will rely on good practice research
and successful health service/university partnerships,” Professor
Hudson said.
How US hospitals and hospital pharmacies are changing for the future
Thomas Thielke, director of pharmacy at the University
of Wisconsin Hospitals, US, gave a perspective on the hospital
of the future and
said that “the pharmacy vision must keep pace”. The structure
of hospital in the US has changed from a facility providing primarily
inpatient services to patients to a health system offering a broad
array of services such as ambulatory care (specialty, surgery and
primary care), long-term care, home health care, infusion and dialysis
centres, outreach services through telemedicine and an extensive
retail service portfolio, he said.
Retail service offerings include
pharmacy, clinical laboratory services, food, dietary and catering
services, occupational therapy and sports medicine, complementary
medicine and nutraceuticals, and diagnostic imaging services.
He explained that, to provide these new services, hospitals have
been reorganised into strategic business units with a combination
of for-profit and not-for-profit corporate structures. These business
units will be marketed through various services believed to drive
financial margins, such as cancer, cardiology and neuroscience services.
Hospitals of the future will invest heavily in information technology,
such as electronic medical records across care settings, smart cards
and telemedicine, to ensure seamless care.
Shared care agreements
and shared governance will exist between medical staff and health
systems to ensure evidence-based practice. Evidence-based patient
care practices will be shared and marketed across services and care
settings, he added. Specialty services will be marketed direct to
consumers with outcome data (eg, actual versus expected mortality,
hospital incidence of infection, patient satisfaction scores, cardiac
and diabetes outcome measures) used to demonstrate safety and improved
quality services.
Turning to the pharmacy structure of the future, he said it will
mimic the health system structure. Hospital pharmacies will develop
new business streams and provide a wide variety of patient care clinical
services from inpatient to outpatient to home care to long-term care.
The pharmacy service will provide retail pharmacies to act as training
sites for pharmacy students, profit centres for the health system
and refill centres for robotics.
The pharmacy service will also provide
mail order services, infusion centres, telepharmacy services, home
intravenous therapy, drug information services, contract management
services to small hospitals, care for older people, specialty care
(eg, respiratory, HIV, transplant) and pharmaceutical research
centres.
There
will be increased use of new dispensing technology, information
technology and an increased patient care role for pharmacists. “Pharmacists
must keep up to date, maintain vision and develop new strategies
to enhance their position within the health system,” Professor
Thielke concluded. |
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The
Pharmaceutical Journal