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Better than an iPad app … a
clinical pharmacist in your
practice team.
Dr Peter Culham
Vanessa Brown
Brendan Duck
RNZCGP GPCME 2014
Can you answer these questions?What is the latest regarding metformin use and eGFR?
When might you use bisoprolol?
When should you use aspirin and warfarin?
Have you audited your...
– Amiodarone patient monitoring
– Methotrexate monitoring
– Citalopram and QT prolongating medicines
!You need a Clinical Pharmacist!
Mr J.R.75 year old male
IHD, MI 1996, MI 2003, multi-vessel disease stented
CHF, severe on basis IHD, echo 2004 EF 21%
Permanent AF on warfarin
GI bleed, duodenitis from
NSAIDs 2009, further 2011
Gout, polyarticular,
tophaceous
Mr J.R.
Warfarin 5mgDigoxin 125mcgOmeprazole 40mgSpironolactone 25mgAtorvastatin 20mgDiltiazem CD 180mgFurosemide 160mgLosartan 50mgSeretide 50mcg BDAllopurinol 200mg (since 2005)
Mr J.R.
June 2011, rash on legs, lifelong eczema but not responding to Locoid
August 2011, intolerable pruritus, excoriated rash over entire body
October 2011, punch biopsy spongioticdermatitis, allopurinol stopped by GPSI. Reducing prednisone 20mg to 5mg
April 2012, severe gout, prescribed colchicine
May 2012, gout left knee, confirmed on aspiration, prescribed colchicine
Mr J.R.
Remains on 2-3mg prednisone, declines allopurinol, urate 0.75mmol/L
Increased tophaceous changes in hands
Frequent use of colchicine for gout attacks
Declines Specialist review
What do you do?
Mr J.E
MIMS Interactions example
What is a Clinical Pharmacist?
Specialist Pharmacist Practitioner
Post-Graduate education and/or significant clinical experience
Undertakes Medicine Reviews = Medicine Therapy Assessment (MTA)
Provides medicine and clinical information services
What's different about a Clinical Pharmacist?
Focus on risk vs benefits for individual patients for each medicine
Applying most recent evidence to specific patient medicine related problems
Recommendations on how to implement treatment plan
Unbiased assessment of emerging medicine evidence and guideline updates
Mrs F.J.
76 year old female
Her current issues include:
Tiredness, cramps and twitchy legs
Constipation, renal function changes
Falling regularly
BP 120/58mmHg Calc CrCl = 21.5mL/min
HbA1c 37mmol/mol Cholesterol levels good
Liver function good
Current meds
Furosemide 80mg mane
Amitrip 25mg nocte
Ezetrol 10mg daily
Aspirin 100mg daily
Quinine 300mg BD
Simvastatin 40mg nocte
Omeprazole 20mg mane
Cholecalciferol 1.25mg monthly
Recommendations
Change simvastatin 40mg to atorvastatin 10mg
Stop omeprazole
Stop quinine
Follow-up
Feeling much better
No longer tired
Birth of clinical pharmacist facilitation?
$1.06 million year on year increase in combined pharmaceutical budget– CPB = community pharmaceuticals
+ pharmaceutical cancer treatments
+ vaccines (from 1 July 2013)
Not sustainable
No ‘low hanging fruit’
Demographics (2013 census)(1)
Population 152,000NZ population 3.4%Māori 23.1%
(NZ 15.4%)
Pacific 4.1%
65-84 years 14.8%
(NZ 11.9%)
85 years 2.1%
(NZ 1.6%)
Aging PopulationItems Dispensed per Capita by Age
Source: Pharmaceutical Claims Data Mart, Ministry of Health (Extracted: 22/4/2011). Note data subject to
change over time.
Under-utilisation
Unmet need
– Access
Disparity in Māori/Pacific Island
– Under-utilisation of medicine
– Higher levels of disease with poorer outcomes
Legend
At goal <53
53 - 64
Not at goal >64
Diabetes Patients HbA1c - 2010
How would
you address
these
problems?
Dr Info
The model
Clinical pharmacist facilitators (1.5 FTE)
Focus on best practice – not cost
To complement the population based clinical pharmacist facilitator (1.0 FTE)
Proof-of-concept
Funded by Hawke’s Bay DHB– working out of Health Hawke’s Bay PHO
– in specific practices (0.5 FTE x 3)
Aims
Interventions targeted at polypharmacy
– ≥ 65 years
– Would not disadvantage Māori, Pacific or NZDep 9/10
Polypharmacy
– patient harm / ADRs
Improve chronic disease
outcomes (CV risk, diabetes)Fulton & Allen 2005
Practice Focuses
Patients >65 years residing in Age Related Residential Care (ARRC) facilities
Patients who are over 65 years living independently in the community
Practice - with high needs population (Māori, Pacific or NZDep 9/10)
The Practices
TE MATA PEAK PRACTICE
GREENDALE FAMILY HEALTH CENTRE
TOTARA HEALTH
Location Havelock North Taradale Hastings & Flaxmere
Targeted population
Patients 65 years and over, living in Age Related Residential Care Facility
Patients, 65 years and over, living independently in the community
Patients with high needs including Māori, Pacific and NZDep 9/10
Enrolled Population 9800 6000 11000
Target Population 175+ 1200 7029
Evolution of role
Relationship building
Initial focus was on patients taking >10 meds
Medicines rather than people
Development of tools to generate referrals
Quality activities
Demand for services
GP Quote
“Initially I had no idea what a Clinical Pharmacist would do for our practice, now I don’t know how I could live without them.”
Totara Health
Individual vs Population Focus– Individual reviews = large benefit for
individuals ≠ large benefit for high needs population
– Focus on population with chronic disease with poor outcomes
– Targeted review of medicines treating chronic disease and recommendations to GP
Diabetes Patients BP Comparison 2010 to 2013
Adherence
Number of risk factors for non-adherence per patient
032%
137%
222%
3 or more9%
Mr T.J.
Male, 63 year old, Cook Island Māori
Labels
– ‘Non-compliant’
– ‘Poor diabetes control due to religious beliefs’
Problem
– Poor understanding of his medicines
– Strong beliefs in value of nutrition and ‘living off the land’
Mr T.J.
Type 2 Diabetes
Recent admission for Heart Failure
Recent admission for cellulitis
Cancellation of cataract surgery
– Poorly controlled hypertension and diabetes
HbA1c 123mmol/mol
BP 195/110mmHg
LDL 4.5mmol/L
Mr T.J.
Intervention
– Improve understanding of medicines
– Sustained adherence to medicines (BP, lipid and diabetes)
BP 120/70mmHg
HbA1c 56mmol/mol
LDL 2.5 mmol/L
No recent HF symptoms
– Teaching others about the benefits of medicines
Te Mata Peak Practice
Primarily Aged Related Residential Care
Aims:
– Reduction in polypharmacy
– Improve medicine safety
Medicine reconciliation on admission
Medicine Therapy Assessment prior to 3/12 review
Medicine related quality initiatives
Digoxin administration and monitoring
Medicines and Falls Risk
Mr A.H.
Male, 76 year old
PAF, heart failure, asthma, osteoarthritis, IHD
3/12 review with locum
Dizzy and unwell
Feeling tired and unable to eat – 10kg weight loss over 2 months
BP 79/50 mmHg
Mr A.H.
Medicines– Dabigatran 110mg bd– Furosemide 120mg mane– Terazosin 15mg mane– Candesartan 32mg mane– Diltiazem 240mg mane– Tramadol SR 100mg bid– Prednisone 10mg mane– Fosamax Plus® weekly– Calcium 500mg daily– Symbicort 200/6 2puffs bd– Budesonide NS 100mcg bd– Salbutamol 200mcg prn
Mr A.H.
Changes– Reduced furosemide to 40mg over time
– Terazosin reduced and switched to tamsulosin
– Candesartan reduced
– Diltiazem reduced
– Dabigatran stopped – GI ADR’s
– Trial discontinuation of tramadol – restarted
– Regular paracetamol started
Results– Feeling better, reduced dizziness, better appetite
Greendale Family Health
Focused on ≥ 65 years living at home
Medicine therapy assessments
Co-ordination of multiple prescribers!
Medicine reconciliation
Clinical guidelines and standing orders
Linkages
Health Hawke’s Bay PHO
Care cluster
Home services
District nurses
Local specialists
Hospital pharmacists
Community pharmacist
Allied health: OT, PT, dietitian, social worker
Tools used – Multi-Med Survey
Tools Used – S.I.M.P.L.E.
Medicine reconciliation
Update medical record 37%
Required clarification 29%
Required a medicine review
as multiple issues 23%
Other interventions 11%
E.g. Advice on syringe driver medicine doses
Medicine information queries
Special authority number follow-upGreendale: 1 December 2012 – 18 January 2013
Prescribing cascade
Mr L - 92 year old: Type 2 Diabetes, Hypertension, Angina, Hypercholesterolaemia
Bladder tumor 2000 + 2003 with urgency issues
Patient’s issues
Dry mouth, foggy head, tired all the time
Constipation, nausea, off balance
Medicines and clinical readings
Metoprolol CR 47.5mg
Felodipine ER 10mg
Aspirin EC 100mg
Cilazapril 1mg
Bendrofluazide 2.5mg
Metformin 1g mane, 1.5g nocte
Vesicare 5mg nocte
Lactulose 30-50ml daily
Laxsol 1-2 nocte
BP 120/70mmHg
No recent HR recorded
HbA1c 46mmol/mol
eGFR 32 mL/min
Na+ 128 mmol/L
No LFTs since 2005
Pharmacist recommendations
Stop Vesicare: ADR outweigh benefit in this patient
Decrease metformin to 500mg BD in view of eGFR and HbA1c
Stop bendrofluazide due to low Na+, eGFR and low BP
3/12 renal function + electrolytes, BP + HbA1c
Annual liver function
Patient follow-up
Follow-up 2 weeks laterPatient feels so much better, no longer needing day time sleepsEating better due to no nausea and mouth less dryHead much clearerBowels opening daily with easeBalance greatly improved
3/12 laterBP 128/70mmHg (120/70)HbA1c 53mmol/mol (46)eGFR 30mL/min (30)Na+ 136mmol/L (128)QoL improvement ++
Benefits to General PractitionerHigh quality unbiased advice
Different set of eyes/focus
Collaborative decision making
Source of information on constantly changing evidence and guidelines
Availability of medicine information
Coordination of multiple prescribers
MOPS audits
Benefits to Practice
Collaboration to manage chronic disease
Increased practice confidence in managing polypharmacy
Contribution to quality improvement of the practice
Review of medicine policies and standing orders
Cornerstone accreditation support
RN quotes – how has the Clinical Pharmacist helped?
“Resource for education of nurses, patients, GPs. Can't imagine not having CP here now as I probably access CP expertise daily…”. Practice Nurse
“Education. Medication Reviews. Input into best practice projects. Liaison between GP and facility when required”. Registered Nurse – ARRC
Benefits to patients
Different focus, asks different questions
Address medicine benefits vs harm
Improved outcomes
Reduced medicine complexity
Coordination of multiple prescribers
Mr H.W.
83 year old
18 months ago admission to HB Hospital CCU with ACS, transferred to Wellington cardiology for stent
Medicines charted incorrectly at Hawke’s Bay Hospital, copied in Wellington, patient discharged home on incorrect medicines
Recognised and stopped, following review by pharmacist
Cost reduction / avoidance
Category Cost $p.a. or per event*
Number of eventsKnown / estimated*
Total DHB savingsKnown / estimated*
1. Community
pharmaceuticals
¥$500,000
2. Falls $0 to $47,000 64 $149,400
3. Reduction in BP § *3 *$100,000
4. Delayed admission to
ARRC$24,000 2 $48,000
5. ED transfer avoided $450 *1 *$450
Total ~$800,000
¥ Hawke’s Bay CPB September 2012 to August 2013§ Reduction in sBP by 10mmHg (1 each renal failure, myocardial infarction, stroke)
Hawkes Bay Future Direction
Clinical Pharmacist Facilitators add value to general practice
1 FTE per 20,000 patients
Ensure access to all areas within DHB
As 1 July 2014, Hawke’s Bay DHB is rolling out this service Hawke’s Bay wide (8 FTE)
We Can Help You
Evidence to support clinical pharmacist role
Experience of implementation
Contact:
– Billy Allan, Chief Pharmacist, HBDHB
William.Allan@hawkesbaydhb.govt.nz
– Di Vicary, Health Hawke’s Bay
pharmacist@healthhb.co.nz
Acknowledgments
Di Vicary, Clinical Pharmacist Facilitator Team Leader
Billy Allan, Chief Pharmacist
Hawke’s Bay DHB
Health Hawke’s Bay
Greendale Family Health
Te Mata Peak Practice
Totara Health
Any Questions?
GP Quote“A couple of years down the track I now have had the benefits of working with 2 amazing people as pharmacy facilitators, and never cease to be amazed at their depth of knowledge and willingness to research any pharmaceutical topic which presents a problem to my colleagues or myself. They have then presented the information in clear and practical fashion making it unnecessary for me to struggle with the long and complicated presentations of scientific papers. In addition their help with sorting potential problems which crop up from time to time in the media has been amazing, finding which patients are potentially affected, and then advising on the best way forward based on the best evidence.”
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