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Pharmacy-based asthma services in Denmark Lotte Fonnesbæk

Pharmacy-based asthma services in Denmark Lotte Fonnesbæk. Danish College of Pharmacy Practice Hillerød, Denmark. Pharmaceutical Care - A system approach. Continuous quality improvement function aimed at the drug use system

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Pharmacy-based asthma services in Denmark Lotte Fonnesbæk

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  1. Pharmacy-based asthma servicesin DenmarkLotte Fonnesbæk Danish College of Pharmacy Practice Hillerød, Denmark Health Promotion Bruxelles 00

  2. 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

  3. 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

  4. 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

  5. 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

  6. 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

  7. Combined evaluation strategy • Formative evaluation and pilot tests • Effect evaluation • Process- and participant evaluation • Health economical analysis • Qualitative interview study Health Promotion Bruxelles 00

  8. 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

  9. Pharmacy activity • The average pharmacy has in the period September 1994 - July 1995 had:15.4 patients/month11.2 pharmacist consultations/month 2.0 telephone consultations/month10.9 reports to the GPs/month • Time consumption:pharmacist consultations 40.5 minutes/consultationtelephone consultations 9.5 minutes/consultationreports 34 minutes/reportadministration, misc. 6 hours/month Health Promotion Bruxelles 00

  10. Effects on outcomes and proces Outcomes Asthma symptom status Asthma morbidity Quality of life (global) Asthma related QoL Satisfaction with health care 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 Improvement in intervention group related to controls after 12 months + 12% 3.2 days per patient saved per year + 34% + 12% no change no change + 27% + 55% + 15% - 21% (n.s.) increase decrease The Danish TOM project

  11. Patient perceived benefits • Asthma symptoms 44-61% • QoL, coping, control 40-60% • Drug use 64-77% • Knowledge 82-92% • Co-operation with pharmacist 75% • Unchanged GP relation 79% Health Promotion Bruxelles 00

  12. GP satisfaction • Programme quality high 85% • Pharmacist competent partner 70% • Patient relationship no worse 93% • Unclear responsibility 14% • Problems with quality <4% General attitudes to the new role are still sceptic Health Promotion Bruxelles 00

  13. 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

  14. 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

  15. 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

  16. Conclusion The project has demonstrated: 1. The Danish community pharmacy can deliver a TOM-programme • 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

  17. 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

  18. 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

  19. Pharmaceutical care models • Basic models • All pharmacies: Dealing with all types of drugs. Offered to all patients Example: Pharmaceutical care at the counter • Group specific programmes • 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

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