Welcome to the September 2009 issue of i2P E-Magazine - Information to Pharmacists.
In this edition I would point you to the Pharmedia link where trends in US pharmacy consumers are noted and matched to the Australian counterpart.
There is a strong similarity between the two countries.
In this commentary a direction and a strategy is suggested.
Please feel free to add your comment in the panel provided at the foot of this commentary, as it is a very important issue for Australian pharmacists.
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Anyone who has followed the story of convenience clinics in the US would have come to a simple conclusion very early in their investigations.
That conclusion would have been that with a few exceptions, the market being serviced in primary care was identical to that serviced by Australian pharmacists.
What was commonly known as “counter prescribing” in Australia became known as the “Minute Clinic” or Rediclinic in the US.
Now we have a development here in Australia where nurse-led clinics are being hosted by pharmacies, with the initial players being the Revive Clinic and the Pharmacy Alliance Group, consisting of 186 franchisees, all based in Perth, Western Australia.
The divide between who writes prescriptions in Australia and who dispenses them has traditionally been seen as an important construct in minimising any conflict of interest.
Will the evolution of nurse practitioners working in pharmacies mean that this protection mechanism for the average Australian (and their taxes) is dissolved?
The National Competition Policy Review of Pharmacy has surely failed to protect the industry from itself.
The objectives of the restrictions include; “ Keeping pharmacy business small enough to facilitate the close personal supervision of their professional operation by the proprietor pharmacists.”
Oh, yeah, just how does that work?
And… “Protecting pharmacy businesses from perceived “unfair competition” and market dominance from large pharmacy-owning corporations and chains and, in some jurisdictions, Friendly Societies”.
Come on, let’s be serious!
I am going to preach to you dear reader.
So what is new with that you will say?
Plenty, because I truly do believe in this creed, which is the belief that without rigorous control of core data integrity the whole e-health plot is flawed.
This boring subject has been raised in these pages several times and there is no doubt the message has sort of got through, but ‘sort of’ is way, way too far from being acceptable. You see this mishmash problem in the pharmacy daily as you use different PDE numbers for the same product when you buy from more than one wholesaler.
You cope with different proprietary product identification and then use the GS1 barcode, on the product pack, to close the sale at the POS (you do, you do use that barcode don’t you!).
All of this means you have to use the wetware technology tool to interpret and map information from one system to another; and the minute you introduce wetware you introduce errors.
All of us have that neat stack of literature either beside our bed, under the desk or overflowing off the kitchen bench. If you are like me some are half read, bookmarked for later more in depth reads or stripped of relevant articles for pharmacy assistant training modules.
I also have a system with my emails and RSS feeds that categorises them to the ‘to be read when I have time file’. On a morning not so long back when I could lay in bed and clear this email in tray I completed a competition on the Pharmacy Daily website for the Pharmacy women’s Congress 2009. To my ultimate surprise I won!!
Comment about the future of pharmacy has been a daily occurrence for seemingly as long as Cook plotted a course up the eastern seaboard.
He hit the rocks, as will many of the so-called “players” attempting to seek proprietorship over parts of the pharmacy puzzle will.
Whether it be fact or Chinese whispers, a number of “core”(sorry Kev) “assets” have the attention of many.
Paracetamol overdosing is emerging as a problem in New Zealand similar to other western economies around the world.
In Australia we have seen some of larger chain pharmacies encouraging the sale of high volumes of paracetamol by deep discount,
Despite protests from a range of pharmacists, little has been done to prevent the spread of irresponsible paracetamol sales.
Pharmacy Boards state they need an official complaint backed up with evidence of adverse events resulting from inappropriate selling.
Liver damage is one adverse event, sometimes requiring a liver transplant to rectify the damage.
There is no easy solution for paracetamol is such a useful drug.
However, there is a strong argument for confining all paracetamol sales to pharmacies irrespective of the potential inconvenience.
In fact, if the general principle applied that all medicines should be sold from a pharmacy, the need to sell other types of merchandise would dissipate.
It's worth a thought
People overdosing on paracetamol
Source Otago Times
The consistent mismatch of approaches to Health IT continue to occur, even with the best efforts of Minister for Health and Ageing (Nicola Roxon) trying to uncover the best way forward.
Costs, both in the government and private sectors, have continually expanded to now stellar $ numbers.
Nicola Roxon's focus on the patient and building out from that point, will see her win the day.
Vendors (such as the Pharmacy Guild) who are canny enough to mould their systems to her view of the world, may eventually get a "nod" of some sort, provided the systems developed genuinely provide a scale of economy, saving development costs as well as delivering the specified benefits to health generally.
Commitment has been made to a National Broadband Network (NBN) and a 16-digit patient identifier so movement to shared health records is nearly possible, with the AMA making some "noises" towards a form of electronic health record (but not a full record).
Source: Australian IT
Proposals that would allow the pharmaceutical industry to provide drug information directly to consumers has been opposed by the Royal Pharmaceutical Society.
This against a EU background to develop an informational infrastructure that could be delivered to all of the European community.
A conflict of interest clearly exists between the public's interest to receive accurate and objective information and the pharmaceutical industry's objective of building revenue and market share.
The New Zealand Pharmacy Guild has commented on the efficiency of Project Stop in Australia and wants to introduce it to NZ pharmacists.
They would also like to extend its use for other medication tracking.
NZ interest may further stimulate a faster uptake of the system in Australia, and by comparing notes in developing the use of the software, governments may be encouraged to fund a range of extensions.
Pharmacies Fight to Stop P-Runners
At last there is a move to sort out the high costs and inefficiencies inherent in Australia's private health insurance system.
Not that the private funds are totally to blame.
Government policies built around the Medicare levy (an extra tax, unless you take out private insurance), the limited range of benefits payable by private funds (because of government controls) has led to a high level of dissatisfaction by people privately insured.
It appears that an entity titled Medicare Select, may be utilised to negotiate and "bulk buy" health services, including those of the state-owned hospitals.
Private health funds, including Medibank Private, would be involved in managing the services on behalf of their members.
This new system has a real potential to reduce major health costs.
Medibank backs system shake-up
In April 2010 the current program for QUMAX (Quality use of medicine in aboriginal community controlled centres) will come to an end.
This was a pilot program and work is being done to look at where to from here?
Like all pilots the program took some time to achieve its goals but achieve them it did.
The evaluation process has been ongoing and the feedback from pharmacists and patients has been excellent.
Will the issues revolving around complementary and alternate medicine (CAM) use ever be resolved?
Outcries from some respected science authorities deride all CAM as "witchcraft", yet most pharmacists would know of at least one good outcome from CAM.
For example, recent research into Traditional Chinese Medicine has uncovered the fact that some herbal remedies for the treatment of heart conditions, help to restore the nitrous oxide (NO) balance in the body, in part by converting nitrites and nitrates absorbed from foods, to beneficial NO (allowing proper dilation of blood vessels, subsequent reduction in blood pressure and gradual depletion of arterial plaque).
This information is now evidence-based, but will you see it appearing in mainstream medical publications?
It is my belief that while many critics of CAM definitely have a valid case for some complaint (particularly when patients are financially exploited), there are many "experts" that have been blind to information that could prove useful (and cheaper) for their patients, simply because they were unaware of the evidence available.
It is simply hidden from view under the sheer volume of total information that is being published and disseminated to health profesionals.
In February 2008 the respected BBC came under fire for providing information on CAM's and withdrew this popular service. I was unaware of this happening and have provided one of the media stories reporting the incident, for others who may have been unaware.
The BBC is a public broadcaster (like Australia's ABC) and serves the interests of the general population free from commercial pressure.
As 41% of people in the UK use CAM the decision to close down the service was certainly a controversial one.
A recent visit to the BBC site demonstrated some CAM news stories, mostly geared towards the potential problems that may be associated with its use.
This is a shame because the BBC are well placed to research evidence surrounding CAM's and provide a much needed and unbiased site for solid information.
The BBC Abandons Its Complementary Medicine Website Due to Pressure
Many firms that licence key software programs are tightening up licencing conditions such as who is entitled to received free licences and what scale of charges apply.
Clients are reluctant to pay fee increases for basically the same software each year, but charitable and aged care organisations will be hit hard for licences that formerly were available to them free of charge.
Obviously there will be some hard negotiating coupled with a review of the actual software required.
One alternative may be to replace Microsoft with the Sun Open Office suite of programs that virtually duplicates the entire range of programs contained in Microsoft Office and comes entirely free of any cost. Open Office can also convert to any of the Microsoft formats.
Pharmacists may like to consider the change as well.
Source: Aged Care Guide
Aged Care IT Investment Put on Hold
With the Baby Boomer retirement revolution due to start in 2010, one of the key needs will be an army of carers to provide home support needs.
Traditionally, this has fallen to family members, usually female.
And with a considerable number of carers being elderly themselves, there will be a human resource shortfall in this area.
One obvious solution is to elevate this activity to that of a career and the necessity to put training processes in place coupled with appropriate remuneration.
Government has made some moves in this regard, but not nearly enough nor in a timely fashion.
There is an opportunity for pharmacy to provide a support service in the form of "Pharmacy in the Home" services.
Creating the outreach is the difficult part, but pharmacies that do not try and participate will lose market share to those who do provide the service.
Carer at home issues raised by NHHRC reform proposals
Source: Aged Care Guide
A walk in the sun to generate a reasonable level of vitamin D3 is said to delay the need for a knee replacement.
But this vitamin is also implicated in heart health, cancer prevention, osteoporosis, arthritis and immune modulation, as in multiple sclerosis.
In fact, it is said that vitamin D3 is involved with over 1100 individual genes in an average person.
Even if you get sun exposure, if you utilise sunscreen preparations the conversion reaction in the skin is virtually negated, or if you have a shower 15 minutes after exposure, the vitamin washes away before being absorbed through the skin.
Old skin is also inefficient as a medium for generating and absorbing the vitamin.
While sun exposure is the cheapest and most optimal way of getting a daily dose of vitamin D3, a back up through oral supplementation is also recommended.
Knee replacements delayed by sun
Source: Aged Care Guide
The following story published by Drug Topics mirrors a trend that has already commenced in Australia.
A more conservative customer/patient is emerging, in part driven by government attempts to convert branded drugs on the PBS to a cheaper generic version.
Harsher economic conditions have also played a major part.
As we all know, not all customer/patients are convinced of the value involved in changing from long established brands, no matter what arguments are offered.
That means two distinct classes of health consumers are forming up within Australian pharmacies.
Note also that the value-conscious health consumer illustrated in the article is less impulse driven and creates a shopping list before leaving home.
And in the background, high levels of government stimulus spending means that the ability for government to fund existing and future services is at risk, and resources will have to be rationed even more than they are currently.
But this trend opens up a range of opportunities for pharmacists to develop a range of services targeted for customers/patients within their homes.
Mark Coleman discusses a "Pharmacy in the Home" concept further along this article.
Con Berbatis is a pharmacy researcher attached to Curtin University in Western Australia. For i2P, he identifies Australian and global research reports that may be useful for pharmacists to include in their own planning initiatives.
Editor : The immediate and sustained management in primary care of patients discharged with heart failure from hospitals has received much attention by medical researchers in Australia. Source: Heartwire Pharmacist-Doctor Teams Help Keep Heart-Failure Patients Out of the Hospital Fran Lowry
The following report is an edited review of a study conducted by the University of South Australia, Adelaide led by Dr Elizabeth E Roughead.
It was published in an international medical journal and has received widespread comment by specialist medical and pharmacy clinicians in the USA.
This topic is presently being studied in heart failure patients discharged from hospitals in Brisbane by a group in the University of Queensland School of Pharmacy.
Editor : The immediate and sustained management in primary care of patients discharged with heart failure from hospitals has received much attention by medical researchers in Australia.
Pharmacist-Doctor Teams Help Keep Heart-Failure Patients Out of the Hospital
August 18, 2009 (Adelaide, Australia) — Collaboration between doctors and pharmacists can reduce medication-related problems and hospitalizations and improve health outcomes in patients with heart failure, Australian researchers report in a study published online before print August 18, 2009 in Circulation: Heart Failure .
A service wherein pharmacists visited heart-failure patients in their homes to review their medications and then reported the findings to the patients' doctors cut the rate of hospitalization for heart failure by 45% in its first year of operation, Dr Elizabeth E Roughead (University of South Australia, Adelaide) and colleagues write.
"Medication-related problems contribute to the problem of hospitalization for heart-failure patients, so educating these patients about drug use is important," Roughead told heartwire . "The home visit part of this program enables time for more thorough education. Clinicians should work with pharmacists to help their heart-failure patients."
A Synergistic Relationship
Dr Mauro Moscucci (University of Miami Miller School of Medicine, FL) agreed that the partnership between pharmacists and clinicians has important and positive implications for improving outcomes for heart-failure patients.
"It's the synergy that is impressive. Improved outcome is due not to pharmacists' visits alone but to the partnership between the two healthcare providers," Moscucci told heartwire .
Roughead and her colleagues sought to determine whether collaborative medication reviews, which have been shown to be successful in improving outcomes for patients with heart failure in randomized controlled trials, would also be successful in a "real-world" setting. Such reviews are nationally funded in Australia.
They retrospectively reviewed administrative claims data on veterans and war widows aged 65 years and older who were prescribed bisoprolol, carvedilol, or metoprolol succinate for heart failure and compared 273 patients who received general practitioner-pharmacist collaborative home medication review with 5444 controls who did not.
The average age of the patients in both groups was 81.6 years. The median number of comorbidities was eight in the group who received the collaborative reviews compared with seven in the group who did not (p<0.0001). The group who received medication reviews also had more prescriptions, more changes in medication prior to their home review, prescriptions from a greater number of healthcare providers, and more hospitalizations.
"We chose to study a veteran population because they are elderly and an appropriate target population for home medicines review services," Roughead explained.
Review Delayed Hospitalization for Heart Failure
The time to hospitalization for heart failure was significantly delayed in the group that received a home medicines review, the investigators found. After adjustment for a variety of confounding variables, only 5.5% of the patients in the review group were hospitalized within a year, compared with 12% of the control group (hazard ratio [HR] 0.55, 95% CI 0.39–0.77; p<0.0001).
Pharmacist Dr Amy Seybert (University of Pittsburgh Medical Center, PA) told heartwire that pharmacists are particularly well-suited for counseling patients. "Definitely. It's what we are trained to do. We explain to patients why they should take their medications and stress the importance of compliance. We tell them how the drugs work. I really think that if patients understand why they are taking something and for what purpose, they are much more apt to be compliant."
Her colleague, Dr Joon Sun Lee (University of Pittsburgh Medical Center), agrees.
"The Australian study confirms much that is known. As treatment regimens, especially medication regimens for heart-failure patients, become more and more complex, the potential for patients to get confused becomes greater. So measures that confirm medication regimens and also check up on patients are effective at decreasing readmissions," he said.
It Works Well Down Under, But Will It Work in the US?
More and more institutions in the US are using pharmacists to help educate patients, usually as part of hospital discharge programs. But Sun Lee questions whether a partnership between pharmacist and clinician as the Australians have would be feasible in the US.
"One of the vulnerabilities and inefficiencies of the US healthcare system is that the collaborative medication review part of healthcare is not rewarded financially. It is an extra cost without reimbursement, whether you are talking about the hospital incurring the cost or the doctor's office. Right now, this is one of the cracks that exist in the delivery care system," he said.
1. Roughead EE, Barratt JD, Ramsay E, et al. The effectiveness of collaborative medicine reviews in delaying time to next hospitalization for heart failure patients in the practice setting: results of a cohort study. Circulation: Heart Failure 2009. Available at: http://circheartfailure.ahajournals.org.Return to home