Community Pharmacists’

Provision of Pharmaceutical Care to the Older Adult

R. GrymonpreL. VercaigneC. MetgeP. Montgomery University of Manitoba

Community Pharmacists’ Expanded Role

“There is strong evidence that clinical pharmacy services add value to patient care and reduce health care utilization costs….clinical services are not widely provided in community pharmacy settings”

The Clinical Role of the Community Pharmacist. Office of the Inspector General, USA. January 1990

“The judicious use of the professional qualifications of pharmacists [is encouraged]”

The Rational Use of Drugs by the Elderly: A Strategy for Action. Government of Quebec. 1995

“National action to ensure appropriate use of all medication will require the active participation of …[seniors, physicians, pharmacists, nurses, governments, industry, family members and caregivers]”

Federal/Provincial/Territorial Strategy for Action. Health Canada. June 1996

Community Pharmacists’ Expanded Role

“The pharmacist is in an excellent position to monitor seniors’ medication use at the point of dispersal”

Optimizing Medication Use in Seniors Receiving Home Care. Canadian Association Community Care. August 1997

“Pharmacists are perhaps both the most important – and least utilized – source of information and education about medications”

Seniors, Diversity & Access: Medication Use & “Hard to Reach” Seniors. National Pensioners and Senior Citizens Federation. May 1997

“Pharmacists can play an increasingly important role as part of the primary health care team……this expanded role would allow pharmacists to consult with physicians and patients, monitor patients’ use of drugs, and provide better information and communication on prescription drugs.”

Building on Values: The Future of Health Care in Canada Final Report. Romanow RJ. (Commissioner) November 2002

Community Pharmacists’ Expanded Role

Cochrane Review: • increased scheduled health services but no decrease in

hospital and ER admissions (1 of 7 studies);• decreased hospital/ER admissions, number of specialty

physician visits, numbers or costs of drugs, improved appropriateness of drugs (6 of 7 studies);

• improvements in targeted condition but no change in quality of life or incidence of ADR (10 of 13 studies);

• improvements in patient adherence (3 of 6 studies)• favorable changes in physician prescribing (9 of 10

studies)

Beney J, Bero L, Bond C. Expanding the roles of outpatient pharmacists: effects on health services utilisation, costs, and patient outcomes (Cochrane Review). In: The Cochrane Library, Issue 1, 2004. Chichester, UK: John Wiley & Sons, Ltd.

Geriatric Pharmaceutical Care

2001: 12.5% Canadians 65+ years old

2026: 20% of Canadians 65+ years old

In Manitoba (1996):13.6% of population 65+ years old

34% of prescriptions dispensed

average of 5 different drugs

Geriatric Pharmaceutical Care

Life expectancy, at birth (1997):75.8 years for men81.4 years for women

In one study of older persons, drugs contributed to 20% of hospitalizationsGrymonpre et al J Am Geriatr Soc. 1988

Community-Based Geriatric Pharmacy Care

6 studies: Positive results:

Improved adherence (1) Excellent physician & patient acceptance (81% & 91%) (1); DRIs

identified and resolved (2) More appropriate drug use (1); more drug changes (1); fewer

repeat prescriptions (1); reduced drug costs (1) Reduced outpatient visits (1); reduced hospitalizations and

hospital stays; reduced health care costs (1) Negative results:

No difference in SF-36 (1); no difference in health decline, falls (1) Poor physician acceptance (28%); DRIs identified but not resolved

(1) No difference in numbers/costs of drug, medication adherence (1) no change in health services use (2)

Community-Pharmacists: Geriatric Pharmaceutical Care

Bernsten C et al. Drugs & Aging 2001;18(1):63-77

Design: randomized (by pharmacy), controlledParticipants: 190 sites, 2,454 patients, 65 years, 4

prescribed meds, oriented x 3, noninstitutionalized Intervention: pharmaceutical care for 18 months;

community pharmacyProcess measures: number of medications & changes;

contacts with GP, GP acceptance & satisfaction; cost analysis; medication knowledge & adherence

Outcome measures: SF-36, hospitalizations, symptoms (self-reported), patient satisfaction

Results: improved satisfaction & symptom control, no difference in other measures

Community-Pharmacists: Geriatric Pharmaceutical Care

Sellors J. SMART. Final report. Sept. 2000

Design: randomized, controlledParticipants: 889 patients, 65 years, 5 prescribed

meds, MMSE≥25, noninstitutionalized Intervention: pharmaceutical care; 24 community

pharmacistsProcess measures: number and types of drug-related issues,

resolution rate of issues, physician response, number of daily medications, medication units, & costs, inappropriate drugs, medication adherence

Outcome measures: medication problems (self-reported), health care utilization and costs; SF-36

Results: DRIs identified in 88% of subjects (mean 3.2); 84% physician acceptance; 57% MD implementation; no difference in other measures.

Community-Based Geriatric Pharmacy Care

Grymonpre RE et al Int J Pharm Pract 2001;9:235-41

Design: randomized, controlled Participants: 135 patients, 65 years, noninstitutionalized,

2 medications Intervention: pharmaceutical care for 1 year; ‘wellness clinic’ Process measures: number and types of drug-related issues,

resolution rate of issues, physician response, number & costs of medications, medication knowledge & adherence

Outcome measures: symptoms (self-reported) Results: 952 issues identified, 29% resolution rate; positive MD

response but 28% acceptance rate (by survey); no difference in other measures

Hypothesis

Community pharmacists have the necessary skills and knowledge to improve drug taking behaviour of older adults

andthe prescribing habits of physicians, therebyoptimizing disease control and reducing theamount of drug-related illness in this segment

ofthe population.

Manitoba Pharmaceutical Care Project

Research Questions:Can a workable model of community-based

pharmaceutical care be provided to physicians and elderly patients?

What is the impact of community pharmacists practicing pharmaceutical care on:• Physician and patient acceptance and implementation of

recommendations?• Use of medications by older persons?

Objectives: To document measures of the patient-focussed pharmacy

care provided: numbers and types of drug-related issues identified;numbers and types of recommendations made;physician and patient acceptance of recommendations;endpoints of plans of action;interview and work-up times; level of remuneration

To measure the impact of comprehensive patient-focussed pharmacy on:medication adherence (primary measure);numbers and costs of medications

Methods: Pharmacy & Pharmacist Selection

Invitation for participation and application Selection based on criteria & signed contract:

demonstrate an understanding of pharmaceutical careremoved from dispensing activities for 6 hours/week recruit 1 client/week x 74 weeksprovide pharmaceutical care to patientsagree to training & group sessionscomplete and submit required documentationaccess to confidential area space & equipment for maintaining filesaccess to library of references

Methods: Process of CareIntervention

Eligible clients perceived to be at risk recruited Intervention: Comprehensive patient-focussed

pharmacy caremedication history develop, implement and document patient

care plans:o identification of drug-related issueso intervention (MD &/or client)o follow-up

Remuneration provided

Methods: Process of Care Action Plan

Characterized by a single or multiple drug-related issue(s) and disease state(s)

Requiring a single or multiple recommendation(s) Resulting in one desired endpointIssues: undertreated diabetes, lack of knowledge, condition

requiring monitoring

Recommendations: add drug, educate client, refer to dietician, monitor blood sugars

Acceptance: client and MD accepted recommendations

Endpoint: blood sugars normalized

Methods: Process of Care Endpoint

Dependent on issue(s) identified in plan of action health outcome - clinical issue

• symptom/measure of disease or side effect: BP, BS, pain, constipation

process endpoint – drug issue• no indication, wrong drug, overdose• when not feasible to look at clinical endpoint

(immunization, osteoporosis, stroke prophylaxis)• education & nonadherence

Status of issue at follow-up ‘partially resolved’ - positive trend but desired target

not reached

Methods: Research design

Design: prospective, nonrandomized, controlled, before-after trial, survey and population based

Setting: community pharmacies Study Subjects: ‘convenience’ sample; 65+

years old; noninstitutionalized; willing to provide signed informed consent; taking at least 1 medication

Control Subjects: randomly selected from Manitoba Health database; 3:1 match by age, gender, and ‘Adjusted Clinical Group’

Methods: Process Measures

Population based measures: medication adherence (primary measure); numbers and costs of medications

Survey based measures (test only): interview and work-up times; remuneration; numbers and types of drug-related issues identified; numbers and types of recommendations made; physician and patient acceptance of recommendations; endpoints of plans of action

Methods: Data analysis

Population based data:Required sample size (total) = 220

10% change in medication adherence

= 0.10 = 0.05 std deviation 25% (Annals 1998)

Mixed modeling procedure (SAS)

Medication Adherence: Cumulative Medication Acquisition (CMA)

CMA* = ‘days supply’ in interval actual number of days in interval

*CMA values are only calculated on medications with 3 or more fills and a ‘prescribed rate’ (quantity dispensed ‘days supply’) of 0.5, 1, 1.5, 2.0, 2.5, 3.0, 3.5, 4.0, 4.5.Using these criteria, DPIN was determined to be a valid measure of medication adherence compared to pill count with 77% concordance & McNemar’s p=0.6837

Grymonpre RE et al [ABSTRACT] Can J Clin Pharm (in press) 2004

Remuneration: Pharmacy Consultation

Grymonpre et al J Res Pharm Econ 2001:11(1):51-61

Results: Pharmacy recruitment

Total number of pharmacies: 11 (selected from 15 applicants)

Total number of test pharmacists: 15Orientation session: May 1 & 2, 1998 (9

hours)Ongoing one-on-one support with

resource pharmacist and groups sessions.

Results: Client recruitment

Study duration: May 1, 1998 - Jan 31, 2000Total number of clients evaluated: 337Total number of eligible clients: 213 (63%)124 Exclusions:

no consent 78 insufficient documentation 46

Results: Demographic Data

Age (n=211) mean sd

77.2 6.5

% Female (n=213) 140 (66%) Prescribed drugs % users (n=213) mean sd (of users)

207 (97%) 6.0 2.9

OTC drugs % users (n = 213) mean sd (of users)

176 (83%) 3.0 2.0

Alternative therapies % users (n = 213) mean sd (of users)

49 (24%) 2.0 1.8

Medical conditions mean sd

213 (100%) 5.8 2.4

Results: Drug Benefit Plans

No 3rd party coverage

70/126 (56%)

Blue Cross 42/126 (33%)

Dept. Veterans Affairs

9/126 (7%)

Other* 5/126 (4%)

*Great West Life, Indian Affairs, Assure

Results: Time required

interview location (n=186) pharmacy home

112 (60%) 74 (40%)

interview time (minutes) mean SD (n=182)

65.4 24.4

work-up/ intervention time mean SD (n=167)

94.1 68.4

remuneration (n=166) mean SD

$78.80 23.30

Results: Action Plans

211 of 213 clients had 1 Action Plan

732 Action Plans were developed mean of 3.5 1.7 per personcharacterized by 945 drug-related

issuesinvolving 1005 recommendations

945 Drug-Related Issues

untreated indication 192 (20%) improper drug storage 32 (3%)

inadequate knowledge 122 (13%) suboptimal regimen 30 (3%)

adverse drug reaction 111 (12%) drug interactions 28 (3%)

monitoring required 91 (10%) drug duplication 18 (2%)

nonadherence 77 (8%) sensory/physical/ cognitive limitation

18 (2%)

primary prevention 57 (6%) subtherapeutic dose 16 (2%)

drug w/o indication 55 (6%) overdose 17 (2%)

improper drug choice 44 (5%) other 37 (4%)

Recommendations to physician

Of 1005 recommendations made:

499 (50%) recommendations involved the MD

114 (23%) of 499 recommendations to MD not made/documented

385 recommendations made to MD:

• start drug 80 (21%)• stop drug 61 (16%) • switch drug 61 (16%)• monitor therapy 54 (14%)• decrease dose 29 ( 8%)• increase dose 28 ( 7%)

• dispensing task 12 (3%) • change dosing time 11

(3%)• refer other hcp 9 (2%)• change dose form 8 (2%)• encourage adherence 5

(1%)• other 27 (7%)

Physician response

Of 385 recommendations made to MD :

physician response to 87 (23%) unknown

Of 298 known responses:• 82% accepted and • 4% partially accepted

Recommendations to patient

Of 1005 recommendations made:

1003 (99.8%) recommendations involved patients

89 (9%) required recommendations to patients not made/documented

914 recommendations to patient

• educate 153 (17%)• start drug 127 (14%)• monitor 122 (13%)• change drug 92 (10%)• stop drug 76 (8%)• disp.related task 48 (5%)• increase dose 43 (5%)

• compliance aid 43 (5%)• decrease dose 41 (4%)• nonpharm. advice 38

(4%)• change time 34 (4%)• enc. adherence 34 (4%)• refer to hcp 25 (3%)• other 38 (4%)

Patient response

Of 914 recommendations made to patient:

patient response to 142 (16%) unknownOf 772 known responses:

• 90% accepted and• 3% partially accepted

Endpoints of 732 Plans of Action

Of 732 Plans of Action:

Endpoint unknown for 278 (38%) Of 454 documented endpoints, 344 (76%)

were resolved or partially resolved.

Medication Adherence: Pre- versus Post- Intervention 199 Test vs 506 Control Subjects

98%

95%

97%

92%

89%

90%

91%

92%

93%

94%

95%

96%

97%

98%

99%

1 year pre-intervention 1 year post- intervention

Control

Test

P=0.0064

Number of Different Drugs: Pre- versus Post- Intervention 199 Test vs 506 Control Subjects

8.6

10.1

9.4

9.8

7.5

8

8.5

9

9.5

10

10.5

1 year pre-intervention 1 year post-intervention

Control

TestP=0.0044

Annual drug costs: Pre- versus Post- Intervention 199 Test vs 506 Control Subjects

$1,005

$1,550

$1,448

$1,685

$1,000

$1,100

$1,200

$1,300

$1,400

$1,500

$1,600

$1,700

$1,800

1 year pre-intervention 1 year post-intervention

Control

Test

P=0.0716

Summary

Some difficulties with process:target recruitment rate of 1 client/week could not be

met23% recomm. involving MD not made/documented 9% recomm. involving patient not made/documented23% of MD responses not determined/documented16% of patient responses not determined/ documented 38% of endpoints not determined/documented

Summary

When process successfully implemented & documented:

99% of clients experienced 945 drug-related issues requiring 1005 recommendations

86% physician acceptance rate 93% patient acceptance rate positive endpoints achieved for 76%

action plans

Benefits: Health & Health Costs

Compared to control subjects, test subjects had:

a lower rate of increase in numbers of drugs (p=0.004)

a lower rate of increase in costs of drugs (p=0.07)

greater improvements in medication adherence (p=0.006)

Conclusions

The delivery & documentation of pharmaceutical care was challenging & required one-on-one support by a resource pharmacist

Older adults experienced several drug related issues Community pharmacists had the necessary skills and

knowledge to identify & resolve these issues which resulted in desired process endpoints and health outcomes

Community pharmacists providing patient focussed care reduced numbers and costs of medications and improved medication adherence

Acknowledgements

Apotex Inc. CIHR (formerly NHRDP)Centre on Aging Manitoba Health Manitoba Pharmacists Manitoba Pharmaceutical AssociationManitoba Society for PharmacistsJenny Kleine Golden (1972-2002)

Acknowledgements

Ms. Marie Berry (Vimy Park Pharmacy) Mrs. Carol Boscow (The Pas Super Thrifty) Mrs. Barbara Bromilow (Pharmasave

Beasejour) Mrs. Donna Campbell (Pharmasave) Mr. Bill Cechvala (Vimy Park Pharmacy) Mr. Terry Chan (Shoppers Drug Mart) Mrs. Wendy Clark (Carman Pharmacy) Mrs. Morna Cook (Dixon’s Pharmacy) Ms. Shelley Cowie (Shoppers Drug Mart) Ms. Camella Crook (C&C PC and Consulting) Mr. Quy Doan (Shoppers Drug Mart) Mr. Brian Dusik (St. James Pharmacy) Mrs. Michele Fontaine (Shoppers Drug Mart) Mr. Myles Haverluck (Dauphin Clinic

Pharmacy) Mr. Warren Hicks (The Pas Super Thrifty Drug

Mart) Mr. Rob Jaska (Medical Centre Pharmacy)

Mrs. Nadine Karpinski (Shoppers Drug Mart)

Mr. Darryl Lancaster (Pharmasave) Mrs. Tracy Lelong-Young (Prescription Plus

Pharmacy) Mrs. Donna McLeod (Pharmasave) Mrs. Nancy Metcalfe (Pfahl’s Drugs Ltd.) Mr. Real Mulaire (St. Pierre Pharmacy) Mrs. Lisa Olench (Pharmasave) Mrs. Julie Penelton (St. James Pharmacy) Mr. Sigfried Pfahl (Pfahl’s Drugs Ltd.) Mr. Don Radley (Pharmasave) Mrs. Nancy Remillard (Pharmasave) Mr. Jay Rich (Shoppers Drug Mart) Mr. Mark Scott (Shoppers Drug Mart) Mr. Trevor Shewfelt (Dauphin Clinic

Pharmacy) Mr. Rolland Villar (Shoppers Drug Mart) Mrs. Sonia Wriedt (Pharmasave)