Clinical Pharmacy in Malaysia: Past ,Present and Future

Clinical Pharmacy in Malaysia: Past ,Present and Future

Noraini bt Mohamad

Senior Principal Assistant Director

Pharmaceutical Services Division

Ministry of Health, Malaysia

11.10.2014

VISION, MISSION & OBJECTIVE

Vision

To provide the best pharmacy service for the health and well being of the nation

Mission

To lead a dynamic pharmacy service emphasizing on the highest level of integrity, professionalism,

and excellence, that meets the application and challenges of the nation

Objective

To ensure quality, safe efficacy, and affordable pharmaceutical and healthcare products are

available and accessible to the public

5

Optimising utilisation of manpower for pharmaceutical services in Malaysia

Providing dynamic pharmaceutical services & progresses with current global development Formulating policies

on drugs & pharmaceuticals

Ensuring drug expenditure is at economic level & quality medicines are available at point of need

Generating

consumer awareness

on issues of rational

use of medicines &

adverse events

through consumer

education

Optimising drug therapy through effective pharmaceutical control & up-to-date clinical & professional services

MAIN OBJECTIVES

Clinical pharmacy is an area of pharmacy concerned with

the science and practice of rational use of medicine.

- with specialized therapeutic knowledge

- with experience and judgment to ensure optimal

patient outcomes

A health science discipline where pharmacist provides

patient care by:

- optimizing the use of medication

- promotes health, wellness, and disease prevention

Definition: Clinical pharmacy

Patient Care

Pharmacist

Doctors

Nurses

Dietitian

ROLE 1: Prepare, obtain, store, secure, distribute, administer, dispense and dispose of medical products

ROLE 2: Provide effective medication therapy management

ROLE 3: Maintain and improve professional performance

ROLE 4: Contribute to improve effectiveness of the health-care system and public health

ROLES OF PHARMACISTS

Joint FIP / WHO Guidelines on GPP :

Standards for Quality of Pharmacy Services

In 1980’s, there was a change from product oriented service to patient focused service.

Concept of Clinical Pharmacy was

introduced in 90’s

Total Parenteral Nutrition

Therapeutic Drug

Monitoring

Cytotoxic Drug Reconstitution

Drug Information

Services

Clinical Pharmacy in Malaysia

The next major step in the drug distribution system

Introduction of an individualised drug supply system on the ward by Unit Dose or Unit of Use systems.

11

These two systems allow the distribution

of drugs to wards to be done in an

efficient and cost-effective manner. It

also minimises medication errors and

wastage.

12 2004 onwards

1. WARD PHARMACY

2. MEDICATION THERAPY ADHERENCE CLINIC (MTAC)

3. DRUG SURVEILLANCE

4. HOME MEDICATION REVIEW (HMR)

5. HARM REDUCTION PROGRAM – METHADONE MAINTENANCE THERAPY

6. QUALITY INITIATIVES

EXPANSION OF CLINICAL PHARMACY SERVICES

Part of medical team in assisting pharmacotherapy decision-making

Activities;

ward rounds

patient assessment

pharmaceutical care plan

bedside counseling

Identify drug-related problems

1 - WARD PHARMACY

Patient assessment

• Past medication history

• Patient’s disease & medication knowledge

• Patient’s medication adherence

Documentation

Patient’s progress note

Lab results

Drug monitoring

Pharmaceutical care issues

Intervention

Documentation

WARD PHARMACY ACTIVITIES

18

Pharmacist

Surgical round Medical round

Medication History Taking

19

Bedside Counseling

Bedside Dispensing

20

Pharmacist

GERIATRIC WARDS

21

Routine Daily Rounds at Medical Wards

Cardiology Round

Pharmacotherapy Round

Ward Pharmacy Statistics (Jan – Dis 2013)

22

Placement of Full Time Pharmacists in the Wards (Major Hospitals)

ICU Medical

Wards

Number of

ICU/Ward 56 236

Number of

pharmacists

(full time)

47 186

% ICU/Ward with full

time pharmacists 83.9% 78.8

Documentation

No. of medication

history taking 213,692

No. of cases clerked 209,441

No. of cases reviewed 258,610

28%

54%

18%

Interventions Done by Inpatient Pharmacists in the Year 2013

Incomplete prescription (27.6%)

1. WARD PHARMACY







• In 2004 , Medication Therapy Adherence Clinics (MTAC) were initiated by the Pharmaceutical Services Division, Ministry of Health Malaysia in ambulatory settings.

• The primary objectives:

• to optimise drug therapy,

• to improve medication adherence and

• to reduce or prevent the occurrence of adverse events and complications due to the drug regimen.

2.0 Medication Therapy Adherence Clinic (MTAC)

Until year 2013, there are 13 types of MTAC offered in MOH, with established protocol published by the Pharmaceutical Services Division:

Types of MTAC

13 MTACs with Established Protocols

Diabetes Stroke

Warfarin Psychiatry

Retrovirus Disease (RVD)

Rheumatology

Respiratory Hemophilia

Nephrology -Chronic Kidney Disease -Post renal transplant -Dialysis

Psoriasis

Geriatric

2014

Hepatitis MTAC Protocol

The 1st MTAC in Malaysia, Post-Renal Transplant MTAC, was started in year 2004

1 5 10 27

98

187

390

561

662 660

0

100

200

300

400

500

600

700

800

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Nu

mb

er

of

Fa

cili

tie

s

Number of MOH Facilities Offering MTAC Services (2004-2013)

13 MTAC

Development of MTAC Services

Ambulatory Care Services : MTAC

Diabetes - MTAC

Warfarin – MTAC

Teaching & Consultation

1. WARD PHARMACY







Increase in medication expenditure but many patients fail to achieve the targeted goals of treatment:

RM 206m medicine expenditure (1995) vs. RM 1.5b (2008) in Ministry of Health Malaysia (MOH)

Only ~26.3% patients who received antihypertensive treatment were able to reach the targeted blood pressure (National Health and Morbidity

Survey 2006)

High value of returned medications (RM 200k in 2008 and RM 700k in 2009)(Pharmaceutical Services Division, MOH).

MOH Strategic Plan (2011-2015) Mid-Term Review – bringing care closer to home with a focus on domiciliary care.

Why HMR?

Current Focus for HMR

Psychiatric

Stroke Geriatrics

Responsibilities of Pharmacist in HMR team

Discussion with patient’s caregiver

Counselling to improve patients’ adherence toward medication

Proper storage and disposal of unused

medication

Involving Pharmacists in the implementation of HMR services will ensure better therapeutic outcomes in the overall management of the

patient.

Total (93)

Hospital 38

Health Clinic 55

Number of facilities offering Home Medication Review (Jan – June 2014)

1. WARD PHARMACY



4. HARM REDUCTION PROGRAM – METHADONE DISPENSING PROGRAM




4. Methadone Dispensing Program

Initiated and collaborated with MOH Disease Control Division in 2005

Objective: To support the success of MOH Methadone Maintenance Therapy program via DOT

Develop strong pharmacist-patient relationships, collaborate with the physician and promote other health care providers to create seamless care and to achieve better retention rate

As June 2014, there are 412 MOH methadone center 58 hospitals, 286 health clinic, 21 GP, 50 National Anti-Drugs

Agency

Service available everyday (365 days/year)

33,000 patient with retention rate at 75%

Methadone Dispensing Process

Patient verification & assessment Dose preparation

Direct Observed

Therapy (DOT)

1. WARD PHARMACY






EXPANSION OF SERVICES

5. Drug Surveillance

National antibiotic usage: DDD (twice a year)

26 types of antibiotics

43 facilities

National Antiretroviral drug usage (yearly)

Surgical Prophylaxis Audit (2014)

Antibiotic Point Prevalence Survey (2015)

National Surveillance on Antibiotics Utilisation in Malaysia 2009-2013

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2009 2010 2011 2012 2013

Mean

DDD/1000 PD797.19 910.21 939.5 1010.781195.28

No. of

Contributors67 81 72 66 64

No. of

Antibiotics18 20 20 22 26

0

20

40

60

80

100

120

0

200

400

600

800

1000

1200

1400

Me

an

DD

D/1

00

0 P

D

2010 2011 2012 2013

No. of

DDD/1000 Pt

Days

1507.14 1677.11 1701.04 2868.87

No. of

Contributors41 41 41 47

No. of

Antibiotics20 20 22 26

0

10

20

30

40

50

60

70

80

0

500

1000

1500

2000

2500

3000

3500

Me

an

DD

D/1

00

0 P

D

↑ 18.25%

↑ 68.65% All wards ICU

Antiretroviral Drug Surveillance - 38 Items monitored

Lamivudine 100 mg (Tab/Cap)

Lamivudine 150 mg (Tab/Cap)

Zidovudine 300 mg/Lamivudine 150 mg (Tab/Cap)

Efavirenz 20 0mg (Tab/Cap)

Efavirenz 600 mg (Tab/Cap)

Indinavir 400 mg (Tab/Cap)

Ritonavir 100 mg (Tab/Cap)

Lopinavir/Ritonavir 200/50 mg- Kaletra®

Stavudine/Lamivudine/Nevirapine - SLN 30 mg (Tab/Cap)

Tenofovir 300 mg (Tab/Cap)

Tenofovir 300 mg/Emtricitabine 200 mg (Tab/Cap)

Didanosine 100 mg (Tab/Cap)

Didanosine 2 g Oral Solution (Bot)




Zidovudine 1 % Inj. (Vial)

Zidovudine 10 mg/ml Syrup (Bot)

Zidovudine 300 mg (Tab/Cap)

Zidovudine 100 mg (Tab/Cap)

Lamivudine 10 mg/ml Oral Solution (Bot)

Raltegravir 400 mg (Tab/Cap)

Stavudine 1 mg/ml Oral Solution (Bot)

Stavudine 30 mg (Tab/Cap)

Stavudine 40 mg (Tab/Cap)

Efavirenz 50 mg (Tab/Cap)

Efavirenz 100mg (Tab/Cap)

Nevirapine 200 mg (Tab/Cap)

Ritonavir 80 mg/ml Oral Solution (Bot)

Lopinavir/ Ritonavir Oral Solution 533/13.3 mg -Kaletra® (Bot)

Abacavir 20 mg/ml (Bot)

Abacavir 300 mg (Tab/Cap)

Abacavir 600 mg + Lamivudine

300 mg (Tab)

Atazanavir 300 mg (Tab/Cap)

Darunavir 300 mg (Tab/Cap)

Nevirapine 50 mg/5 ml Oral

Suspension (Bot)

Lopinavir/ Ritonavir 100/25mg –

Kaletra®

Tenofovir DF 300 mg +

Lamivudine 300mg (Tab)

Antiretroviral Drug Surveillance

No State Hospital Health Clinics

2011 2012 2013 2011 2012 2013

1 Perlis 94 105 109 12 12 15

2 Kedah 540 594 642 75 78 90

3 Pulau Pinang 1,378 1,706 1,441 30 53 59

4 Perak 806 956 1,057 48 52 70

5 Selangor 4,280 5,548 3,893 210 350 452

6 HKL 306 251 94 NA NA 0

7 Negeri

Sembilan 397 371 236 102 193 154

8 Melaka 270 224 569 82 103 116

9 Johor 1,425 1,241 1,313 247 302 423

10 Pahang 451 509 518 89 118 153

11 Terengganu 349 459 470 60 92 104

12 Kelantan 1,358 451 322 97 167 247

13 Sabah 712 669 691 82 98 88

14 Sarawak 465 519 608 3 9 7

15 WP Labuan 5 7 10 0 0 0

16 WPKL 17 0 7 12 296 449

Total 12,853 13,610 11,980 1,149 1,923 2427

1. WARD PHARMACY







Pharmacist as part of the team in Hospital Clinical Research Centre

Part time or fulltime

As preceptor for PRP research projects

Involvement in clinical trials

Involvement in QA studies

Quality Initiatives – R & D

National R & D Conference (organized every 2 years) as a platform to present findings..

How it happened?

1. Strengthen Services Establishment of Clinical Working Committees

International partnership

Development of training module and teaching material

Establish training centers

Appointment of dedicated preceptors

2. Standardization of Practices Development of guidelines & protocols

3. Quality Assurance –Clinical & Pharmacy Practice Audit (ADAF)

Approaches to Success

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CARDIOLOGY

CRITICAL CARE

RESPIRATORY

PSYCHIATRIC

DIABETES

PHARMACOKINETICS

NUCLEAR PHARMACY

PARENTERAL NUTRITION

ONCOLOGY

NEPHROLOGY

METHADONE

RETROVIRAL DISEASE

GERIATRICS

ANTIBIOTICS

PSORIASIS

HEPATITIS

EMERGENCY

RHEUMATOLOGY

Clinical Pharmacy Working Committees / Task Forces, MOH

For more information, please visit MOH website:

www.pharmacy.gov.my

Protocols

Fully Registered Pharmacist : Peer review for ensuring everyone have the same

knowledge and skill

Provisionally Registered Pharmacist Validation Counseling Technique : Must

pass at least 80% types of counseling within 2 months of report duty

Counseling Guidelines

Minimum counseling

target was set for every

health facility

MTAC RESPIRATORY

MTAC DIABETES

Training Modules

MTAC WARFARIN

Pharmacists with postgraduate degrees in MOH, Malaysia

Master 372 Clinical Pharmacy : 190

PHD 19 Pharmacotherapy /Clinical : 6

Developing Expertise…. Short courses/attachment

-Abroad or local

Postgraduate study : Master & PhD

* Fully/Partially sponsored by the government

Numbers of

Pharmacist

Area or Fields Country

40 Oncology (including

palliative care)

Pediatric

Rheumatology

Cardiology (Warfarin /Heart

Failure)

Critical care

Emergency

Neurology (Stroke)

Geriatric

Nuclear

Psoriasis

Pharmacogenomics

USA

Australia

Korea

UK

Singapore

Canada

etc…

Short Course Attachment / International Partnership in Clinical Pharmacy

2006 -2014

Sharing and gaining knowledge

Develop expertise in specialized area

QUALITY ASSURANCE - AUDIT ON CLINICAL ACTIVITES

Objectives

To ensure compliance towards the protocols and guidelines

To ensure the monthly data reported in line with the activities carried out

To find out problems or obstacles faced by pharmacists

Challenges

Restricted budget

Attachments (local or overseas)

Training @ excellence centers

Short courses

Manpower:

Multitasking and variation in job distribution ( types of facilities)

High turnover rate of pharmacists (transfer, resign)

Reluctant to expand job scope

No Key Performances Indicator –ward Pharmacy, HMR

THE FUTURE OF CLINICAL PHARMACY SERVICES

CREDENTIALING & PRIVILEGING

1. Ward Pharmacy Service:

• Critical Care

• Pediatrics

• Medical

2. MTAC:

• Diabetes

• Respiratory

• Warfarin

• Retroviral Disease

• Nephrology (Chronic Kidney Disease, Renal Transplant, Dialysis)

BCPS certification

Pharmacotherapy

Ambulatory

Nuclear Pharmacy

Oncology Pharmacy

Psychiatry

Emergency Medicine

Antibiotic Stewardship Program

Development of ASP Protocol for pharmacy

WAYS AND MEANS..

1st BCPS Examination in Malaysia..2012 UITM Puncak Alam

2012 Specialties :

Pharmacotherapy, Ambulatory, Psychiatry & Oncology

18 BCPS certified (MOH)

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2013

• Specialties : Pharmacotherapy, Ambulatory

• 10 BCPS certified

BPS 2012-2013

SPECIALIZATION

Generalist

Paraspecialist

Specialist

Infectious Disease

Nephrology

Cardiology

Oncology

Critical Care Pharmacy

Carrier Pathway Pharmacist as Specialist

PHARMACY PRACTICE &

MANAGEMENT

CLINICAL PHARMACY

RESEARCH Regulatory Pharmacy

PHARMACY ENFORCEMENT

Pharmacy Practice Manager

Clinical Pharmacist Director/ Consultant

Research Pharmacist Manager

Regulatory Pharmacist Director/ Consultant

Enforcement Pharmacist Director/ Consultant

Senior Principal Pharmacist

Senior Principal Clinical Pharmacist

Senior Principal Research Pharmacist

Senior Principal Regulatory Pharmacist

Senior Principal Enforcement Pharmacist

Principal Pharmacist

Principal Clinical Pharmacist

Principal Research Pharmacist

Principal Regulatory Pharmacist

Principal Enforcement Pharmacist

Senior Pharmacist Senior Clinical Pharmacist

Senior Research Pharmacist

Senior Regulatory Pharmacist

Senior Enforcement Pharmacist

Pharmacist Clinical Pharmacist

Research Pharmacist

Regulatory Pharmacist

Enforcement Pharmacist

PROPOSAL FOR PHARMACIST CAREER PATHWAYS

CLINICAL PHARMACY/ PHARMACOTHERAPY SPECIALIST

Pre-requisites

Post graduate degree – master in clinical pharmacy

Board Certification – Board of Pharmacy Specialty (optional)

2 year post graduate residency program in field of specialization

WHAT NEEDS TO BE DONE

Framework for specialisation program

Identify priority areas for recognition of specialisation

Needs and acceptance by doctors

Number of pharmacists already involved

Grandfather pharmacists who can be accredited

2 year Residency Program

Areas and assessment mechanism

Preceptors – pharmacists and doctors

Training hospitals

Proposed Residency Program

R1 6/12

R2 6/12

R3 6/12

R4 6/12

This Residency Program is proposed as a duration of 2 years, and divided into 4 semester, 6 months each.

Participants will be assessed in the forms of written examinations, research in specialized area, viva, presentation and etc.

Endless

opportunity for

clinical

pharmacist

to grow…..

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Hopefully, in two years time, pharmacists can be recognized

as specialist in Malaysia

Clinical Pharmacy in Malaysia: Past ,Present and Future

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