A New Kind of“High-Risk” & “High-Cost”

IndividualAn Introduction to

Medication Therapy ManagementServices

A New Kind of“High-Risk” & “High-Cost” Individual

BUT patients who take multiple medications and have multiple chronic conditions

These are predisposed to: Multiple providers (Fragmented

care) Poly-care (multiple prescribers) Poly-pharmacy (multiple

dispensers) Interactions – Drug/drug,

drug/disease, drug/age Inappropriate / unnecessary

prescriptions Inadequate monitoring for

efficacy and toxicity Non-compliance/inappropriate

use Suboptimal outcomes

• NOT individuals with a specific disease

• NOT individuals on a specific medication

A New Kind of“High-Risk” & “High-Cost” Individual – contributing factors

Patients: inappropriate drug information, misleading beliefs, patient demands/expectations

Prescribers: lack of education and training, lack of objective drug information, misleading beliefs about drug efficacy

Workplace: heavy patient load, pressure to prescribe, lack of adequate lab capacity & insufficient staffing

Drug Supply System: unreliable suppliers, drug shortages and expired drugs supplied

Drug Regulation: non-essential drugs available, non-formal prescribers and lack of regulation enforcement

Industry: promotional activities misleading claims

The major factors can be categorised as those deriving from patients, prescribers, the workplace, and the supply system including industry influences, regulation, drug information and combinations of these factors.

Pharmacists: An Untapped Resource

All these” high risk” “high cost” individuals have a common root problem: Inadequate

oversight/monitoring of complex drug regimens consisting of multiple medications that have the potential to adversely effect each other’s actions as well as the individual’s chronic conditions

Who better to deal with these situations than a pharmacist?

Pharmacists are the most accessible healthcare provider, yet few individuals ever have meaningful interactions with a them…Why? Pharmacists do not get paid

out of medical insurance Pharmacies only get paid if a

prescription goes out the door

Pharmacists receive more training on the safe, effective and appropriate use of medications than any other healthcare professional

Clinical Pharmacy in Primary Healthcare

Clinical Pharmacy is a very new concept in Africa. In America and Europe, its taking place with the aim of giving the patient the best, but also the safest and most cost effective drug therapy, including health care education and medicine intervention where appropriate.

Within the health care system, clinical pharmacists are experts in the therapeutic use of medications

Clinical pharmacists are a primary source of scientifically valid information and advice regarding the safe, appropriate, and cost-effective use of medications

They routinely provide medication therapy (treatment) evaluations and offer recommendations to patients and other health care professionals.

• The current health care system focuses primarily on acute, reactive care.

• There is much room for improvement of health care, with emphasis on disease prevention and better disease management of chronic diseases.

Promoting Health Care Improvement (HCI)

The goal in mind, is to promote Health Care Improvement (HCI) through the following:

Maximising the clinical effect of medicines, i.e., using the most effective treatment for each type of patient

Minimising the risk of treatment-induced adverse events, i.e., monitoring the therapy course and the patient's compliance with therapy

Minimising the expenditures for pharmacological treatments born by the insurers and patients, i.e., trying to provide the best treatment alternative for the greatest number of patients.

It is very difficult for patients to do what they do not understand, so the first step in equipping patients to take a more active role in their health care is to educate them.

Maximising the clinical effect of medicines - Rational Drug Use

This point implies that rational use of drugs, especially rational prescribing, should meet certain criteria:

Appropriate indication: prescription is entirely based on medical rationale and that the proposed drug therapy is an effective and safe treatment

Appropriate drug: the selection of drugs is based on efficacy, safety, suitability and cost considerations

Appropriate patient: no contra-indications exist and the likelihood of adverse reactions is minimal, and the drug is acceptable to the patient

“Rational use of drugs requires that patients receive medications appropriate to their needs, in doses that meet their own individual requirements for an adequate period of time, and the lowest cost to them and their community” (WHO 1985)

Minimising the risk of treatment-induced adverse events - Rational Drug Use

This point implies that rational use of drugs, especially patient use, should meet certain criteria:

Appropriate information: patients are provided with relevant, accurate and clear information regarding their condition and the medication(s)

Appropriate monitoring: the anticipated and unexpected effects of medication(s) is appropriately monitored

“Rational use of drugs requires that patients receive medications appropriate to their needs, in doses that meet their own individual requirements for an adequate period of time, and the lowest cost to them and their community” (WHO 1985)

Minimising the expenditure for treatments - Rational Drug Use

80/20 rule – 20% of the patients are responsible for 80% of the medical insurance costs:

Who are the “20 percenters”? Patients with:

Diabetes Heart Disease Cancer Adverse Drug Reactions

Many of the medications actually end up causing more harm than they good because they are not prescribed, used, or monitored appropriately

Hence spending more money dealing with the problems that medications cause than we spend on the medications themselves

Non-compliance: a significant challenge in chronic disease care

“Rational use of drugs requires that patients receive medications appropriate to their needs, in doses that meet their own individual requirements for an adequate period of time, and the lowest cost to them and their community” (WHO 1985)

The Promise of Team-Based Medicine

The team approach is really our only hope for sustaining our healthcare system into the future due to factors including: Expanding pace and scope of

discovery in medical science and technology

The growing complexity of medical care

Increasing number of people with chronic illnesses (and their changing expectations)

Resource constraints

The goal is the achievement of definite outcomes toward the improvement of quality of life for the individual, the family, and the community

our solution - Hybrid ModelSemi – Dispensing MTMS

The insurer identifies specific patients that are in need of certain medication-related interventions and refers them to clinipharm for execution

Two basic types of Medication Therapy Management (MTM) Services are offered Dispensing-related: Brief

therapy-specific interventions designed to inform and educate

Non-dispensing related: More time-intensive encounters that leverage the pharmacist’s unique expertise in reviewing complex drug regimens to assess for appropriateness; monitor for efficacy, adverse reactions and drug interactions; promote compliance and appropriate use, etc.

The focus of attention moves from the drug to the single patient or population receiving the drug(s)

Dispensing related MTM

Appropriate indication: misunderstood

The physician had intended for the patient to use one prescription during the first month and the other prescription as a dose increase for the second month.

Appropriate monitoring: the outcome

The pharmacist educates the patient according to the doctor’s instructions and averts a potentially life-threatening situation.

Would this happen in any current community pharmacy set-up?

Due to poly-pharmacy interventions like this would rarely happen

Example :A patient presents to clinipharm with a new prescription for a similar diabetes medication as given a week prior. The pharmacist notes that the two prescriptions used together would likely result in an overdose. The pharmacist contacts the doctor to clarify the dosing regimen.

NON-Dispensing Related MTMS

In reviewing these medications, the pharmacist identified and resolved nine drug therapy complications of various severities – including three to lower drug costs and one which potentially averted an ER visit.

These sessions are:

More intensive services for patients who are high-risk

Services are arranged by appointment (not at the pharmacy counter…not even in the pharmacy)

Pharmacist reviews patient’s profile, meets with patient (in person), identifies and address barriers to appropriate, cost-effective care

Makes recommendations that are sent to patient’s healthcare team for consideration and action as appropriate/necessary

Example:A Pharmacist conducts a Comprehensive Medication Review for a patient taking multiple medications. During the review the pharmacist found the patient was taking seven prescription drugs along with twelve over-the-counter products.

Evidence of Value – case study

Drug Dosage

Carbamazepine 200 mg 1 bd

Furosemide 40 mg 2 mane

Digoxin 0.25 mg 1 mane

Potassium chloride 600 mg

1 tds

Clonazepam 0.5 mg 1 bd

Warfarin 5 mg 1 d

Actrapid 3 ml penset 5 units d

Protphane 3 ml penset

5 units d

Valsartan + HCTZ 80/12.5

1 mane

Nifedipine SR 30 1 mane

celecoxib 200 mg 1 bd

Gender : Non-epileptic female Age : 76Complaints : Patient feels that she is taking too many different types of medication and is not getting better. Her health was deteriorating rapidly.

Evidence of Value – case studyThis is a very good example of poly-pharmacy where one drug is prescribed to counteract the side effects of another.An interesting link between the side effects of the drugs and the signs of deficiency of the vitamins, electrolytes and enzymes.

Findings

She suffers from side effects of most of the drugs

She suffers from chronic fatigue.

She has uncontrolled blood sugar and hypertension.

She has a very poor quality of life, walking with crutches and in constant pain all over her body (fibromyalgia?)

Her monthly expenditure on medication is enormous

She started off with hypertension about 15 years ago. Now she also suffers from arthritis, diabetes, arteriosclerosis and blood clotting problems.

Evidence of Value – recommendationsThis might strongly indicate that her current disease status is drug and life style induced

To the patient

Use health tips to lose weight, avoid all soft drinks, sweets and processed sugars

Start an exercise program 30 – 40 mins exercise per day

Embark on a supervised detoxification program and start drinking at least 2-3 litres of water daily.

Eat more raw fruits and vegetables, but consult with a dietician

Minimise animal proteins, fats and dairy products. Avoid all processed foods.

Minimise salt intake, eat more fibre rich foods.

Take supplements with omega 3 and 6, folic acid and vitamin b12

Evidence of Value – recommendationsThis might strongly indicate that her current disease status is drug and life style induced

To the healthcare team

Potential metabolic disorder and drug toxicity especially digoxin and carbamazepine blood levels

Investigate LFTs & RFTs

Potential increased CVS incidence Depleted B12 and folic acid lead to

increased homocystein levels = associated with increased CVS incidence

Evaluate electrolyte and mineral balance

diuretics that can cause severe dehydration, hypovolemia and interference of mineral utilization.

Hydrochlorothiazide together with nifedipine can cause the development of kidney stones (hypercalceamia) and interference of the thyroid in long-term use

Evaluate appropriateness of all medication = reduction in healthcare expenditure

Drug Therapy Problems Identified

% % ofof DrugDrug TherapyTherapy ProblemsProblems

IndicationIndication Unnecessary Drug TherapyUnnecessary Drug TherapyNeed Additional Drug TherapyNeed Additional Drug Therapy

12 %12 %26 %26 %

EffectivenessEffectiveness Ineffective DrugIneffective DrugDosage too LowDosage too Low

9 %9 %17 %17 %

SafetySafety Adverse Drug ReactionAdverse Drug ReactionDosage too HighDosage too High

19 %19 %10 %10 %

ComplianceCompliance NoncomplianceNoncompliance 7 %7 %

Total Number of Drug Therapy Problems:Total Number of Drug Therapy Problems: 100 %100 %

why choose clinipharm

The goal is the achievement of definite measurable outcomes toward the reduction in healthcare expenditure

Outcomes to be reported quarterly for each insurer are:

Cost effectiveness / savings per individual cases and combined

No of cases of treatment duplicity

No of cases of inappropriate medication

No of cases of cured individuals

No of cases of disease and/or drug induced diseases

Questionable compatibility with current community pharmacy business model vs. clinipharm’s consultancy based business model

Conclusions Follow the dollars and you will never get lost

Place critical importance on Strategies aimed at utilizing existing providers and relationships

through promotion of practice change Ability to use team-based care & community resources

Our service includes on-going disease education and therapy counselling, comprehensive patient education and adherence management.

Plot 6/8, Kisozi ComplexKyagwe Road, Nakasero, Kampala, UgandaTel: +256 (39) 217 7996Cell: +256 (77) 622 5224Cell: +256 (70) 122 5224

Fax: +27 (86) 572 2387Email: info@clinipharm.co