KNMP – The potential for pharmaceutical quality services€¦ · KNMP – The potential for...

Booz & Company

This document is confidential and is intended solely forthe use and information of the client to whom it is addressed.

The Hague, 14 November 2012

KNMP – The potential forpharmaceutical quality services

Prepared for KNMPBooz & Company

Context

The KNMP has asked Booz & Company to assess the revenue potential for quality based servicesfor pharmaceutical care in The Netherlands

This document represent the draft deliverable for phase 1 that was agreed between KNMP andBooz & Company – It provides a quantitative view on the cost savings potential for health insurersif pharmacy quality services are implemented on a large scale

The KNMP can approve a next phase of the study: a combined stakeholder analysis and high-level implementation plan

1


Summary potential for Quality Services p. 2Detailed Potential calculations p. 22

2

– Medication Review– Continuity of Care– Therapy Adherence

International Experience with Quality PaymentsReferencesAppendix

p. 22

p. 43

p. 82

p. 89

p. 55

p. 99


Executive Summary (1/6)

3

This report evaluates the potential for investing inquality services of pharmacists

Pharmacists generate income based on the quantity ofprescriptions they provide to patients, which includesthe prescription fee and trade margin. This year theNZa introduced new performance definitions that allowhealth insurers to pay pharmacists for quality servicesin addition to the traditional prescription fee. The newperformance definitions allow pharmacists to investmore time in their role as care provider.

High quality pharmaceutical care not only offers valuefor patients, but can also save costs in other parts ofthe health care system. Our analysis shows forexample that corrections of doctor prescriptions bypharmacists save € 120–160 million in short term acutehospitalizations.

Pharmacists face increasing revenue pressure becauseof declining trade margins and a recent decrease inmedication sales. Smaller margins increase the needfor efficiency but increasing efficiency typically results inless time spent per patient, leading to a decline inquality of pharmaceutical care. This can in turn lead toan increase in total health care costs due to moremedication errors and more hospitalizations caused byadverse drug reactions.

The KNMP has asked Booz & Company to explore thecost saving potential of additional pharmaceuticalquality services. The analysis can serve as a basis forcontracting discussions between pharmacists andhealth insurers. The report is limited to thequantification of benefits from additional pharmaceuticalquality services. It does not address the costs of theimplementation of the quality services.



Our analysis indicates € 500–750 million value ofpharmaceutical quality services

Booz & Company evaluated the potential for threequality services that can be delivered in addition to thequality services associated with medication dispensing.– Medication reviews for patients above 65 that are

using five or more medications– Pharmaceutical support of patients following hospital

discharges– Pharmacist support to encourage therapy adherence

for heart disease, diabetes and COPD/Asthma

Our macro estimates are based on the extrapolation ofa large selection of individual studies

We identified the main drivers of potential cost savingsfor each of the three quality areas such as the reductionin hospitalizations due to medication reviews. Wereviewed national and international scientific researchto assess the potential cost savings. The studies wereweighted according to perceived relevance for a broadpatient population.

The studies showed a wide variation in results.Differences may be attributable to (1) differences in thedesign of the intervention (e.g. regular phone calls orgroup session to follow up therapy adherence), (2)differences in patient groups (e.g. patients in elderlyhomes or patients living at home), (3) differences incountries or (4) differences in the leading actor (e.g. acommunity pharmacist or a clinical pharmacist).

4



5

Based on the results of individual studies we defined arange of what is plausible in the Netherlands. Ourassessment was based on a weighted average of thestudy results, on the conservative side of the range.Combining the results from scientific studies with Dutchmarket data (such as the number of hospitalizations,number of patients etcetera) we derived macroestimates for the total cost saving potential. The rangeof these figures reflects the uncertainty that isassociated with extrapolating results from individualstudies. Further research is needed in this area, inparticular in the Netherlands. The lack of local dataforced us to develop estimates based on national andinternational studies. International results are notnecessarily fully achievable in the Netherlands. Hence,we took a conservative approach in our estimates.

Medication reviews for patients above 65 that are usingmultiple medications

In a medication review, a pharmacist typically performsan overall assessment of the appropriateness of thecombined medication usage of a patient. In theliterature, medication reviews are recommended forpatients over the age of 65 and for those who use 5 ormore medications. This group accounts for the lionshare of medication usage as more than 50% of allmedication is prescribed for people aged 65 and above.Further, more than 90% of all medication costs forpeople over the age of 65 are in the group of patientsusing 5 or more medications. A comprehensivemedication review will improve overall medicationappropriateness for patients (as measured by theMedication Appropriateness Index) and is shown tolead to a decrease in drug related problems



6

Our analysis indicates a € 150–200 million potential incost savings gained from medication reviews. The firstdriver of cost savings is a reduction in medication costs.Scientific studies suggest that on average 10-12% ofmedications are discontinued safely as a result ofmedication reviews. The second driver is prevention ofhospitalizations. Research indicates that medicationreviews contribute to a 15-17% decline inhospitalizations relating to Adverse Drug Relatedevents. The current analysis excludes less directadverse effects of medication interaction such as theimpact of medication on the effectiveness of chemo-therapy.

Pharmaceutical support of patients after hospitaldischarges (continuity of care)

Pharmaceutical support after hospital discharges aimsto optimize patient transition between differentproviders of health care. Hospitalizations often lead tosubstantial changes in the medication profile ofpatients, and create a need for pharmaceutical support.Pharmacist-led continuity of care interventions areshown to improve appropriateness of medication andreduce preventable adverse drug events afterdischarge.

Our assessment of the cost saving potential in this areais € 100–160 million. The main driver for cost savingsfor pharmaceutical support after hospital charges is theprevention of repeat hospitalizations. Scientific studiessuggest that the hospitalization risk can be reduced by35 to 50%. Any cost benefits from discontinuingmedication or from switching to cheaper alternativemedications have not been included in the assessment.



7

Pharmacist support in encouraging therapy adherence

Non-adherence to therapy is a common and persistentproblem in health care. Our health care system is morefocused on identifying health problems and selectingthe most appropriate treatment, than on ensuring thatprescribed therapies are followed-up appropriately. Inresearch literature there are many examples ofdiseases programs focused on improving medicationadherence. They show a variety of interventions, suchas education, monitoring, proactive follow-up,counseling or innovations in packaging. Theseinterventions may have specialists, GPs, nurses orpharmacists in the lead. Disease programs wherepharmacists are in the lead are shown to be effective inimproving therapy adherence.

In this study we focused on three significant diseaseswhere medication therapy plays an important role: heartdisease, diabetes, asthma / COPD. Therapy adherenceis associated with lower hospitalization risk on the shortterm, and in the long term, it also reduces the likelihoodof complications (few peer reviewed studies quantifythis effect). In this study we take a conservative view onthe total potential given the focus on three diseases andthe focus on short term hospitalization risks only (i.e. 1-2 years in most studies). An indicative calculationsuggested that in diabetes alone there could be anadditional € 150 million potential for long termcomplication reduction.

Our assessment is that € 250-400 million potential costsavings in short term hospitalizations can be realizedwith therapy adherence programs for the selecteddiseases. These potential savings take into account acorresponding increase in medication costs, as wehave assumed that extra medication administered willalso lead to additional medication sold instead ofreduction of unused medication waste.



8

We leveraged studies that indicate the results ofadherence improvement interventions and studies thatcompared hospitalizations of patients that are adherentabove a certain threshold with patients that are lessadherent than the threshold. Although the latter studiesdo not provide direct evidence that interventions doimprove adherence, they provide a good indicationabout the potential of improved adherence. In particular,studies indicate that adherence improvementinterventions can reduce short-term hospitalizations by15-25% for heart disease, 25-45% for diabetes and 20-60% for Asthma / COPD patients.

A compelling long-term vision, no quick changes

This potential is neither easy nor quick to realize.Firstly, it will require incentive models that allowpharmacists to invest in these initiatives. Timeavailability is a serious constraint. Secondly, it willrequire incentive models for general practitioners andhospitals that reward collaboration with pharmacists.Lastly, it will require a long-term integral view on carecontracting. A positive business case on a per-patientbasis does not guarantee positive macro-level results.Even if benefits from fewer hospitalizations and fewercomplications are realized on a per-patient basis,hospitals may reallocate resources to the treatment ofother patients, obscuring any macro benefits.

Australia, Germany, UK and Denmark have alreadymade steps in remunerating quality services. Thepotential for wins in quality and wins in long-term costcan and should underpin a compelling long-term visionin health care in the Netherlands as well.


Dispensing medications generate pharmacist revenues

9

Pharmacy Remuneration2010 in € MN

1,269Total

1,232

Non-WMG 37

Prescription fee

Per Pharmacy1)

2010, in €Drivers

183 MN prescriptions Maximum remuneration

€7.91 per prescription

8 MN prescriptions (ata trade margin)

€ 623,000

€ 18,0002)

€ 641,000

1) 1980 pharmacies in Netherlands in 2010 (SFK, 2011)2) Buiten-WMG margin based on G-standard selling price. In practice margin likely to be lowerSource: SKF Data en Feiten (2011), Booz & Company analysis


There is a risk that increasing revenue pressure on pharmacistscrowds out time for quality

10

Less Time for Quality Can Lead toHigher Overall Health Care Costs

Cost for unnecessarymedication

Hospitalizations as result ofdrug related events

Doctor visits due to drugrelated events

Lower DispensingRemuneration

Increased DispensingEfficiency

Compensates forLower Remuneration

Less Time per Patientfor Pharmaceutical

Care

Reduced MedicationAppropriateness and

Patient Support

Higher Cost(e.g. Unnecessary

Medication,Hospitalizations)

The Dysfunctional Circle of EfficiencyMay Lead to Less Time for Quality and Higher Costs


Although quality is not directly rewarded, pharmacists alreadycreate substantial value with quality interventions

11

Pharmacist Interventions Improve Healthand Avoid Drug Related Problems

Study Examples

Pharmacist Interventions Improve Qualityof Medication Prescriptions

Pharmacist intervene with a frequency of 4.3% of allprescriptions, yielding an average of 14.3 adjustments

per pharmacy (Buurma, 2004)

Pharmacist medication review on evidence basedguidelines strongly improves the appropriateness of

medication (Gallagher, 2008)

Medication reviews lower the number of medicationrelated hospitalizations especially for patients with

multi-morbidity - factor 2 reduction on average(Leendertse, 2008)

Pharmacist interventions reduce drug relatedproblems in elderly patients (>65 years) by 16.3%

(Vinks, 2009)

In >50% of the cases, pharmacist intervention on aprescription is aimed at preventing a drug related

issue – in half of the cases the prevented drug relatedissue would have had severe consequences (e.g.

hospital admission) (Buurma, 2004)

In elderly patients (>70 years) nearly half of themedication could be safely discontinued;

successful discontinuation of medication is likely toimprove health in 88% of cases (Garfinkel, 2010)

Medication reviews could yield over 94 MN in theNetherlands through a reduction of hospitalizations

(Leendertse, 2012)


Currently, prescriptions that are positively modified bypharmacists avoid € 120 – 160 MN in drug related hospitalizations

12

Total EconomicValue Added

~€120–160 MN

# of Interventions thatPrevented an ADR

~936,000

PrescriptionsPositively Modified

0.49%2)

Interventions Aimedat Preventing ADRs

49%2)

# of PrescriptionsAnnually191 MN1)

X

Average Cost perHospitalization€3,816–5,4613)

Prevention ofHospitalization

3%4)

Average Cost PrimaryCare per Patient

€77.025)

Economic ValuePrevented Primary

Contacts~€10 MN

Economic ValuePrevented

Hospitalizations~€110–150 MN

Prevention of PrimaryCare Contact

13%4)

X

X

Current Value Added through Modified prescriptionsIn €

1) SFK data en feiten (2011)2) Buurma (2004)3) CVZ handleiding kostenonderzoek, Leendertse (2008)4) Westerlund (2009)5) CVZ kosten per verzekerde exclufief inschrijfgeld (2011)Source: Booz & Company analysis

ILLUSTRATIVE


But there is strong potential for increased focus on quality – e.g.40-60% of medication related hospitalizations is preventable

13

Bates(1995)

Lindley(1992) 50%

Beijer(2002) 24%

28%

HARM(2006) 46%

Beijer(2002) 87 – 88.5%

Drug Related Hospitalizations% Preventable Drug Related Hospitalizations1)

Elderly

Non-Elderly

40 - 60%WeightedAverage

Elderly

All

All

ILLUSTRATION

1) Percentage from total drug related admissionsSource: Beijer (2002), Lindley (1992), HARM (2006), Bates (1995), Booz & Company Analysis


Studies suggest that more time for pharmaceutical quality couldhave a large savings potential in other health care costs

14

Example Assessment for Preventing HospitalizationsPotential Additional Savings, In € MN

EXAMPLEHOSPITALIZATIONS

Leendertse (2012): EUR 96 MN Beijer (2002): EUR 390-490 MN

Retrospective study todetermine the percentage ofdrug related hospitalizations in 4hospitals in the Netherlands

From screening of unplannedadmissions, 5.6% was related toan adverse drug event (ADE);46.5% of these hospitalizationswas assessed to be preventable

Meta-analysis to determinepercentage of drug relatedhospitalizations based on meta-analysis

Drug related hospital admissionsaccount for approximately 15 –20% of total hospital admissions,of which ~50% was said to bepreventable

Note: Savings calculation based on total population, not elderly patients exclusively; differences in study outcome likely due to definitions of numerator/denominatorSource: Leendere (2012), Westerlund (2009), Beijer (2002), Booz & Company analysis


Since 2012, there are possibilities for health insurers to paypharmacists for additional quality services

15

MedicationDispensing(receptregel)

MedicationInstructions

MedicationReview

Continuity ofCareHospitalization

Continuity ofCare Discharge

SelfManagementEducation

SelfManagementCounselling

MedicationRelated TravelCounselling

DiseasePreventionTravelCounselling

Mutual Services

Performance Definitions NZa

Distribute prescription medication instandard/weekly form

Check correctness/safety of prescription

1

2

3

4

5

6

7

8

9

10

Provide usage instructions in case of firsttime issuance or non-compliance with userinstructions

Periodically review individual (elderly)medication therapy of patients with chronicmedication use

Conduct one-on-one interview with patient Ensure correct transition of medication

details to other providers of care

Conduct one-on-one interview with patient Provide clear guidance on medication

therapy, incl. changes due tohospitalization

Provide education in group format onself-management to optimizemedication utilization (medicationadherence/utilization)

Provide counselling per individualpatient’s request on potential drug-drug interactions in medication therapy(e.g. combination prescription/OTC)

Provide counselling per individualpatient’s request on medicationutilization and storage during travelling

Provide information per individualpatient’s request on risk of diseasesfor certain travel destinations

Support other healthcare providers inexecution of activities as definedunder performance definitions


We have assessed the cost savings potential of quality servicesacross the entire value chain

16

Key Areas of Added Value in the Medication Process

Medication Dispensing

Medication UtilizationSupport

Care Transition(Hospitalization)

Regular MedicationCheck

MedicationDispensing

Medication Review Disease Programs Continuity of CareQualityService

Driver ofRevenue

Quantify of distributedmedication

Decrease in unnecessarymedication per patient

Decrease in hospitalizations

Increase in therapyadherence

Decrease in hospitalizations Decrease in doctor visits

Decrease in re-hospitalizations

Decrease in primary carevisits

Description

Pharmaceutical evaluation ofmedication through periodicassessment of individualpatients’ pharmacotherapy

Provide overview ofmedication pre-hospitalization and closelytrack required medicationpost-hospitalization

Provide chronic diseasepatients with continuoussupport to increase therapyadherence and to stimulateself-management

Distribute prescribedmedications and provide userinstructions (identifymedication errors ifapplicable)

MedicationProcess

Source: Prestatiebeschrijvingbeschikking NZA, Booz & Company analysis


The quality services captures in this study capture six of the NZaperformance definitions

17

BackupMatching NZa Performance Definition

Medication Review

Disease Programs

Continuity of Care

3. Medication review

Scope

2. Medication Instructions 6. Self Management Education 7. Self Management Counselling

4. Continuity of Care Hospitalization 5. Continuity of Care Discharge

Medication Dispensing 1. Prescription fee (receptregel)

Other 8. Medication related travel counselling 9. Diseases prevention travel counselling 10. Mutual services

Quality Service


Our estimates are based on findings from peer reviewed studiesand public statistics – 3 Step approach

18

High Level Approach Implications

Step 1:LiteratureResearch

Defined key quality and cost metrics to study (e.g.medication appropriateness, reduced number ofhospitalizations)

Defined a list of (national and international) scientificstudies for each of the quality services based on thedefined metrics

We leverage national andinternational experience for theDutch Context

Step 2:Evaluation of

Studies

Selected metrics that can be translated into cost estimates Weighted studies based on relevance to the business case

– E.g. extent to which study population is representativefor a broad age-based population, extent to which acommunity pharmacists as in the lead, study size

Assessed an appropriate range to extrapolate

We assess the potential, not thehow (e.g. we do not assess howtherapy adherence can be improved).The how might vary depending onpharmacist preferences

Step 3:QuantifyMacro

Potential

Extrapolated results to relevant Dutch population toestimate macro potential for the large scale roll-out of suchinterventions– Based on relevant metric ranges from step 2– Based on public statistics (e.g. average medication cost,

and average cost of hospitalizations

We extrapolate small scale resultsto the macro level (assuming thatwhat can be proven to be achieved ona small scale setting can be achievedon a larger scale)


Focusing on quality of pharmaceutical services could deliver EUR500 – 750 M savings throughout the heath care system

19

Total

500-750

Therapy Adherence(Heart Diseases,

Diabetes, Asthma COPD)

Medication cost dueto increased therapyadherence

250-400

Hospitalizations

Medication Cost

Primary Care~

Continuity of Care

100-150

Medication Review

150-200

Potential Quality ServicesIn € MN

Note: Numbers roundedSource: Booz & Company analysis

Excluding thecost related toproviding the

service


Pharmacies could add substantial value with quality services ontop of current dispensing revenues

20

Dispensing

Quality Services

Total

~ 900-1,000

641

260-375

TherapyAdherence

130-200

Continuity ofCare

55-75

MedicationReview

75-100

Distribution

641

Potential Quality Services Per Pharmacy€ x000

Indicative PotentialPer Service Delivery ~€ 1501) ~€2002)

550-6501)reviews

~300 hospitalizationsleading to changes inmedication profile

Quantity of ServicePer Pharmacy(estimated)

1) Based on total number of elderly with polypharmacy2) One-third of hospitalizations are for elderly ( 600.000 in The Netherlands per year, CBS) of which 50% is estimated to lead to a medication change (Mansur 2008). 50% of medication

cost is with people under 65 (SFK, 2011) . Hence total number of hospitalization leading to change in medication profile estimated at ~ 600.0003) Depending on disease and eligibility criteria (numbers are indicative for inclusion therapy adherence for diabetes insulin patients and for all COPD / Asthma patients)Source: Booz & Company analysis

PER PHARMACY

~€150-3003)

Number of eligible chronically illof patients (e.g. 140diabetes patients on insulin)


Quality service provide a compelling visions for long term earningmodels, but savings are neither quick nor easy to realize

Incentive models that reward pharmacists to invest in quality services– Time available for pharmacists for quality services is constrained– Remuneration is needed to allow pharmacists to invest time and resources in quality services– Illustrative calculation: Assuming that a pharmacist would spend 2 days a week on additional

quality services, he could do 4 medications reviews, this would lead to 150-200 medicationreviews per year, and no time for other quality services

Incentive models for general practitioners and hospitals that reward collaboration withpharmacists– Collaboration with other care providers is needed and desired

A long-term integral view on care contracting of insurers– A positive business case on a per-patient basis does not guarantee positive macro-level results.

Even if benefits from fewer hospitalizations and fewer complications are realized on a per-patient basis, hospitals may reallocate saved resources to the treatment of other patients,obscuring any macro benefits.

21

Requirements


Business Case for Value Added ServicesDetailed Business Cases

22


International ContextReferences


NL

Medication review is typically targeted at elderly polypharmacypatients

23

Distribution of # of Medicines Per Age% Age Category, 2009

Ø 45%

≥ 10 Medications

5-9 Medications

1-4 Medications

0 Medications

85+ year

100%

20%

28%

21%

31%

75-84 year

100%

16%

35%

30%

19%

65-74 year

100%

8%

30%

40%

22%

1 Medication Review

Polypharmacy≥5 Medications

1-4 Medications

Total Costs

€ 1.9 BN

94%

6%

Cost of Medication 65+Per # of Medication

Source: van Dijk (2009), SFK (2011), Booz & Company analysis


Medication reviews will improve overall medicationappropriateness for patients

24

4.30

3.56

4.51

Hanlon (1996)

Spinewine (2007) 18.98

Crotty (2004b)

Crotty (2004a)

Medication Appropriateness Score (MAI)1)2) Study Population MethodologyMean Change in MAI Score

1 Medication Review

208 elderly outpatientsreceiving care at VeteransAffairs Medical Center

Age > 65 years with at least5 chronic medications

Evaluated the effect ofsustained clinicalpharmacist interventions

Intervention joint effortpharmacist – GP

203 patients receivinggeriatric care by a specialistclinical pharmacist

Age > 70 years

Tested effect ofpharmaceutical care onGeriatric patients in additionto acute GEM3)

10 high-level aged carefacilities

154 residents experiencingmedication problems /challenging behaviours

Determined effect of caseconference interventions byteam of multidisciplinaryhealth professionals

110 adults, mean age 82.7years

Discharged from 3metropolitan hospitals to 85long term care facilities

Evaluated effect ofpharmacist transition carecoordinator to assesoutcome after firsthospitalization

Increase inAppropriateness

EXAMPLES

1) Selection based on Cochrane review by Patterson (2012) on interventions to improve appropriate use of polypharmacy2) Medication Appropriateness Index based on 10 dimensions to determine in appropriate prescribing – positive change indicates increased appropriateness, see appendix for more details3) Geriatric Evaluation and ManagementSource: Crotty (2004, a-b), Spinewine (2007), Hanlon (1996), Patterson (2012)


Medication review has a potential €150–200 MN in reducing drugcosts and preventing hospitalizations

25

Total Potential Cost Savings

150-200 MN

Prevention ofHospitalizations

55-90 MN

Reduction inMedication Cost

95-110 MN

Total Savings Medication ReviewIn € MN

A B

1 Medication Review

Source: Booz & Company analysis


Large scale medication reviews will lead to €95–110 MN costsavings on medication only

26

A Medication Cost

Direct Savings Potential Medication Review

Maximum SavingsPotential Through

Medication Reviews~ €95–110 MN

# of Patients1.2 MN

Reduction in #Medication per Patient

0.8–0.9 Medications

Number of Elderly> 65 Years

2.6 MN1)

% Poly-Pharmacy45%3)

Average Spend perMedication

€98.47 Average #of Medication

8.051)

Average SpendMedication€792.672)

X

/X

Reduction inMedication

10–12 %

Average # ofMedications

8.051)X

1) Garfinkel et al. (2010), Spinewine (2007), Schmader (2004)2) SKF data en feiten (2011)3) van Dijk (2009)Source: Booz & Company analysis


Medication reviews on average lead to a 10–12% reduction of thenumber of medications per patient

27

Reduction in MedicationIn %, Per Patient

A Medication Cost

Reduction in Medication Increase inMedication

DETAILS ONNEXT PAGES

-3-3-1

112336667

91113131415

2728

32

-15

4660

WeighedAverage10-12%


Study outcomes were weighted to account for differences inintervention, setting and population across studies

28

Population

Intervention

Representation

Description

Accounts for differences acrossstudy population such ascommunity patients vs.hospitalized patients

Ranking

2 – Community / long term care facility1 – Clinical patients

Accounts for differences ininterventions to better measure theeffect of medication reviews vs. a

more broad intervention

2 – Medication Review1 – Broader Intervention incl. medication

review

Accounts for differences in sizeand thus representativeness of

study population across thedifferent studies

3 – Population > 5002 – Population 300 - 5001 – Population <300

Category

A Medication Cost


203 patients receiving geriatric care bya specialist clinical pharmacist

Age > 70 years

Tested effect of pharmaceutical care onGeriatric patients in addition to acuteGeriatric Evaluation and Management

1.0

Community dwelling patients Mean Age = 82.8 years 87% had >3 comorbidities

Determined drug discontinuation basedon Good Palliative-Geriatric Practice

Mean follow up time of 19 months1.7

Community dwelling patients > 5 medications Total population 133

Determined effect of medication reviewon regimen changes for polypharmacypatients in ambulatory clinic

1.7

69 medically underserved patients inAlabama (USA)

High risk of medication issues

Researched effect pharmaceutical careon prevention / detection of medicationrelated problems on high risk patients

1.3

236 Hospitalized patients >65 Discharged with 3> medications for

chronic conditions

Studied impact of clinical pharmacistson geriatric drug prescribing in terms ofappropriateness of prescribing

1.0

3230 nursing home residents dividedover intervention /control group in 52nursing homes in Australia

Assessed effect of a clinical pharmacyprogram, incl. education and medicationreview on drug use

2.0

136 patients mostly >80 years old,living at home

4> medication

Researched effect of home-basedmedication review via two communitypharmacist visits

1.7

Patients >65 years 2> prescribed drugs Non-institutionalised elderly

Measured the impact of a community-based pharmaceutical care model incommunity health clinic

1.7

Details on Medication Reduction (1/3)

29

13

14

15

27

28

32

46

60

Lenaghan (2007)

Grymonpre (2001)

Roberts (2001)

Spinewine (2007)

Taylor (2003)

Garfinkel (2010)

Lipton (1994)

Williams (2004)

A Medication Cost

Study Population MethodologyMedication ReductionIn %, Per Patient

Weight1)

1) Weight based on 3-point scale, details provided in appendix


208 elderly outpatients Age > 65 years >5 chronic medications

Evaluated the effect of clinicalpharmacist interventions on patients atVeterans Affairs Medical Centre

1.3

Long term care home setting Total 278 patients in 7 care homes >5 chronic medications

Assessed effect of patient specific caseconferences between GP, pharmacist,and care home employee

1.7

Patients > 65 years >6 chronic medications Total of 174 patients included

Investigated impact of communitypharmacist -led intervention onmedication

1.7

872 hospitalized patients >80 years >2 drugs daily at discharge

Determined whether home basedmedication review by pharmacist affectshospital readmissions ratios

1.3

Clinical setting with geriatric patients Patients of 11 Veteran affairs hospitals > 65 years, meeting frailty criteria

Reviewed if in/outpatient geriatricevaluation and management reducessuboptimal prescribing in frail elderly

1.7

Meta analysis of 32 studies; 17studies included pharmacist –ledmedication reviews

Results not included as individualstudies of meta analysis reviewed andincluded

NA

1188 community dwelling patients >65 years 1> repeat prescriptions

Determined impact of pharmacisteffectiveness in reviewing repeatprescriptions

2.0

121 hospitalized patients >60 years >4 more regular medications

Evaluated pharmacist-conducted follow-up at home of high-risk elderly patientsdischarged from hospital

1.0


30

3

6

6

6

7

9

11

13

Nelissen (2007)

Vinks (2009)

Holland (2005)

Schmader (2004)

Holland (2007)

Furniss (2000)

Naunton (2003)

Hanlon (1996)

A Medication Cost


Weight1)



332 patients >65 years > 2 chronic disease states > 4 prescribed medications

Studied effect of pharmacist medicationreview on costs based on medicalrecords and patient interviews

2.0

3025 patients Mean age 67 years

Studied impact of home / GP basedmedication review by researchpharmacist enacted with GP

1.3

Multicounty study – 7 countries 2454 elderly patients 65> years

Measured outcomes of structuredpharmaceutical care program providedby European community pharmacists

2.3

661 elderly care home residents >65 years >1 medication

Measured impact of pharmacist-conducted clinical medication reviewbased on medical records

2.3

132 patients >65 years >4 medications taken regularly

Investigated the efficacy / costeffectiveness of pharmacistconsultation in family practice

1.7

190 elderly patients Studied effect of patient counsellingduring 5 domiciliary pharmacy visits onmedication management

1.0

24 family practice sites Ontario 889 community dwelling elderly .5> medication taken daily

Examined whether face-to-faceintervention by a community pharmacistcould reduce # of medication units

2.3

159 patients >65 years 3> medications taken daily

Described process of pharmaceuticalcare used by community pharmacists inspecific project, incl. patient phone call

1.7


31

-3

-3

-1

1

1

2

3

Kassam (2001) -15

Sellors (2003)

Begley (1997)

Sellors (2001)

Zermansky (2006)

Bernsten (2001)

Mackie (1999)

Krska (2001)

A Medication Cost


Weight1)



Potential discontinuation differs per drug category – Laxatives andanti-inflammatory can most frequently be safely discontinued

32

Change in Prescriptions per Drug Category# of Prescriptions per Year, per 1000 Residents

Drug Category % Reduction Post Intervention

Antacids -25%

H2 Antagonists 0%

Laxatives -52%

Digoxin -6%

Diuretics 7%

Antibacterials -17%

NSAIDs -43%

Paracetamol 18%

Psycholeptics -19%

Benzodiazepines -23%

Significantly reduced as result of intervention1)

A Medication Cost

Medication review for2325 residents of longterm care residence in

Australia

1) As reported in studyNote: Study based on medication review in intervention and control nursing homes in AustraliaSource: Roberts (2001), Booz & Company analysis


Our estimate for savings in medication costs by medicationreviews seems in line with results from other studies

33

3738

70

879899

107

159

185190

Ø 133

Zermansky(2006)

Roberts(2001)3)

Bos(2005)

Our EstimateSorensen(2004)1)3)

Zermansky(2001)

Bond(2000)2)

Krksa(2001)

Trygstad(2009)

Nelissen(2007)1)

McMullin(1999)

295

Medication Cost SavingsIn €, Per Patient per Year


A Medication Cost

1) Medication Cost after one year timeline; diverging trend in medication cost intervention-control2) Based on patients not needing full quota of medication as result of monitoring/ controlling repeat prescriptions3) Article explicitly mentions potential higher cost savings in other countries due to relatively low cost level of medication in AustraliaSource: McMullin (1999), Nelissen (2007), Trygstad (2009), Krska (2001), Bond (2000), Zermansky (2001), Sorensen (2004), Bos (2005), Roberts (2001), Zermansky (2006) Booz & Company analysis


Details on Cost studies (1/2)

34

107

159

185

190

295

Bond(2000)

Krksa(2001)

Trygstad(2009)

McMullin(1999)

Nelissen(2007)

Study Population Methodology

Total 259 patients Average age 60 years Total of 1226 interventions

Assessed impact of pharmacistinitiated interventions on costs

6 university hospital pharmacistrecorded patient specific costrecommendations

Medication Cost SavingsIn €, Per Patient per Year

Long term care home setting Total 278 patients in 7 care

homes At least 5 chronic medications

Assessed effect of patientspecific case conferencesbetween GP, pharmacist, andcare home employee

Long term care residents inNorth Carolina, USA

Total of 5255 patients withpolypharmacy

Total patients 332 Patients >65 years > 2 chronic disease states > 4 prescribed medications

3074 patients on repeatprescription subscribed in 62community pharmacies

Evaluated impact of large scalemedication therapy program ondrug cost per patient

Pharmacist review of drugregimens

Studied effect of pharmacistmedication review on costs

Review based on medicalrecords and patient interviews

Compared a communitypharmacist managed repeatprescribing system withestablished methods

A Medication Cost

Note: For studies that did not report a 1-year follow up period (e.g. 30 days), 1-year savings were calculatedSource: McMullin (1999), Nelissen (2007), Trygstad (2009), Krksa (2001), Bond (2000), Booz & Company Analysis


Details on Cost studies (2/2)

35

37

38

Zermansky(2006)

Roberts(2001)

Bos(2005) 70

Sorensen(2004) 98

Zermansky(2001) 99

4 general practices 1188 patients aged >65 At least 1 repeat prescription Community dwelling

Determined effectiveness ofpharmacist review of repeatprescriptions throughproactive consultations

3 Australian states Total of 400 patients Mean age 72 years, avg. 8.5

medications per patient

Examined effectiveness ofmultidisciplinary servicemodel delivering medicationreview in the community

839 patients evaluated Elderly, polypharmacy

patients selected bypharmacist

Evaluated the effect of jointeffort between pharmacistand GP to reduceunnecessary polypharmacy

3230 nursing home residentsdivided over intervention/control group in 52 nursinghomes in Australia

Assessed effect of a clinicalpharmacy program, incl.education and medicationreview on drug use

661 elderly care homeresidents

>65 years >1 medication

Measured impact ofpharmacist-conductedclinical medication reviewbased on medical records

A Medication Cost

Study Population MethodologyMedication Cost SavingsIn €, Per Patient per Year

Note: For studies that did not report a 1-year follow up period (e.g. 30 days), 1-year savings were calculatedSource: McMullin (1999), Nelissen (2007), Trygstad (2009), Krksa (2001), Bond (2000), Booz & Company Analysis


Medication reviews can realize €55–90 MN in savings by avoiding~15,000 hospitalizations

36

Total Cost SavingsHospitalizations

Elderly~€55–90 MN

Total ReductionMedication Review

15–17%

ADR RelatedAdmissions Elderly

(Polypharmacy)101,611

Cost PerHospitalization€3,816–€5,461

# of HospitalizationsElderly

651,1871)

ADR RelatedHospitalizations

16.60%2)

% Polypharmacy94%3)

Total Reduction #Hospitalizations

Elderly14,900–16,900

Average Cost PerHospitalization4)

€457–€654

Average Days ADRHospitalization5)

8.35

X

X

X

X

B Hospitalizations

Direct Savings Potential Medication Review

1) CBS Statline 2008, Clinical hospitalizations only2) Beijer (2002)3) Calculated value – see p.174) Referentie prijzen CVZ, Leendertse (2008)5) Beijer (2007), Leendertse (2008)Source: Holland (2007), Vinks (2009), Hanlon (1996), Krska (2001), Zermansky (2006), Royal (2006) , Booz & Company Analysis


Pharmacist are highly effective in identifying DRPs, of whichalmost half has potentially severe consequences

37

Interventions to Reduce Drug Related Problems% of Positively Modified Prescriptions

Westerlund(2009) 32.0%

Buurma(2004) 49.8%

Pharmacist are effective inidentifying DRPs when

checking patientsprescriptions

B Hospitalizations

50%

Ø100%

Low

High

High

10.8%

27.7%

Low

47.0%

14.5%

Severity of DRPsIn % of Total Pharmacist DRP Interventions

Seriousness

Probability

Source: Buurma (2004), Westerlund (2009), Booz & Company analysis


Medication reviews are shown to identify additional drug relatedproblems

38

Sorensen(2004)

16%

Hanlon(1996)

Vinks(2009)

35%Schmader(2004)1)

27%

25%

Drug Related ProblemsDecrease after Medication review, % of Patients

Comprehensive MedicationReviews result in a significant

decrease in DPRs

B Hospitalizations

EXAMPLES

1) Study completed in Clinical Geriatric settingSource: Sorensen (2004), Hanlon (1996), Vinks (2009), Schmader (2004), Booz & Company analysis


Medication reviews can lead to a reduction in hospitalizations ofby 15–17%

39

Reduction in HospitalizationIn %, Per Patient

Reduction in Hospitalization Increase inHospitalization


-22-20-15

-10

-2-1

238

1316161719

252529

3839

-88-36

758082

B Hospitalizations

WeighedAverage15 – 17%


Patients from 2 health maintenanceorganizations

Selected ambulatory high risk patients

Studies the impact of 3 alternativemodels of pharmacist consultation onuse and cost of healthcare services

2.0

69 medically underserved patients (AL) High risk of medication issues

Researched effect pharmaceutical careon prevention / detection of medicationrelated problems on high risk patients

1.3

LA skilled nursing facility Determine outcome of clinicalpharmacist assuming responsibility fordrug management of geriatric patients

1.0

160 ambulatory adults Full Article NA1.0

3074 patients on repeat prescriptionsubscribed in 62 communitypharmacies

Compared a community pharmacistmanaged repeat prescribing systemwith established methods

1.7

121 hospitalized patients >60 years >4 more regular medications

Evaluated pharmacist-conducted follow-up at home of high-risk elderly patientsdischarged from hospital

1.0

Full Article NA1.0

332 patients >65 years > 2 chronic disease states > 4 prescribed medications

Studied effect of pharmacist medicationreview on costs based on medicalrecords and patient interviews

2.0

Details on Hospitalization reduction (1/3)

40

25

29

38

39

59

75

80

82

Cummings (1984)

Thompson (1984)

Taylor (2003)

McCombs (1998)

Krska (2001)

Lai (1998)

Naunton (2003)

Bond (2000)

Study Population MethodologyHospitalization ReductionIn %, Per Patient

Weight1)

B Hospitalizations


661 elderly care home residents >65 years >1 medication

Measured impact of pharmacist-conducted clinical medication reviewbased on medical records

2.3

Multicounty study – 7 countries 2454 elderly patients 65> years

Measured outcomes of structuredpharmaceutical care program provided byEuropean community pharmacists

2.3

3230 nursing home residents dividedover intervention /control group in 52nursing homes in Australia

Assessed effect of a clinical pharmacyprogram, incl. education and medicationreview on drug use

2.0

Full article NA1.0

Long term care residents in NC, USA Total of 5255 patients with

polypharmacy

Evaluated impact of large scalemedication therapy program on drugcost per patient

1.0

208 elderly outpatients Age > 65 years >5 chronic medications

Evaluated the effect of clinicalpharmacist interventions on patients atVeterans Affairs Medical Centre

1.3

Patients > 65 years >6 chronic medications Total of 174 patients included

Investigated impact of communitypharmacist-led intervention onmedication

1.7

126 geriatric patients with risk-factorsfor non compliance

Studied impact of a pharmacist consultclinic on the care of elderly outpatients 1.0


41

3

8

13

16

16

17

19

25Zermansky (2006)

Bernsten (2001)

Roberts (2001)

Stowasser (2002)

Trygstad (2009)

Hanlon (1996)

Vinks (2009)

Lim (2004)

B Hospitalizations


Weight1)


362 Patients >75 years 4 or mode medications Discharged from hospital

Investigated effectiveness of a pharmacydischarge plan in elderly hospitalizedpatients

1.3

1054 ambulatory, high risk patients at 9Veteran Affairs medical centers

Determined effect of clinical pharmacistson economic resource use andhumanistic outcomes

1.3

132 patients >65 years >4 medications taken regularly

Investigated the efficacy / costeffectiveness of pharmacist consultationin family practice

1.7

236 Hospitalized patients >65 Discharged with 3> medications for

chronic conditions

Studied impact of clinical pharmacists ongeriatric drug prescribing in terms ofappropriateness of prescribing

1.0

136 patients mostly >80 years old,living at home

>4medications

Researched effect of home-basedmedication review via two communitypharmacist visits

1.7

Total 259 patients Average age 60 years Total of 1226 interventions

Assessed impact of pharmacist initiatedinterventions on costs in 6 universityhospitals

1.0

872 hospitalized patients >80 years >2 drugs daily at discharge

Determined whether home basedmedication review by pharmacist affectshospital readmissions ratios

1.3

24 family practice sites Ontario 889 community dwelling elderly >.5 medication taken daily

Examined whether face-to-faceintervention by a community pharmacistcould reduce # of medication units

2.3

53 patients discharged from hospital totheir own home

Mean age 77.5 years

Investigate how seamlesspharmaceutical care could be delivered

Hospitalizations not as primary outcome1.0


42

-88

-36

-22

-20

-15

-10

-2

-1

2Nazareth (2001)

Smith (1997)

Sellors (2003)

Holland (2005)

McMullin (1999)

Lenaghan (2007)

Lipton (1994)

Sellors (2001)

Malone (2000)

B Hospitalizations


Weight1)



43




Continuity of care services aim to optimize the patient transitionbetween different providers of health care

44

2 Care Continuity

Physician Hospitalization

Continuity of Care

Continuity of Care Illustrated Continuity of Care Services

Continuity of care aims to optimize thepatient transition between differenthealthcare providers

Frequently these transitions impose a riskof adverse events on the patients due tochanges in therapy and medication

Formalizing the process by means of astructured approach and defined rolesand responsibilities could minimize therisk of transition

Pharmacist could play an important role inassuring continuity of care due toaccessibility from a patient perspective,overview of medication and expertise

Goal of the pharmacist would be toensure correct utilization andappropriateness of medication to optimizetherapy and avoid DRPs

Source: Roughead (2002), Booz & Company analysis


Hospitalization and discharge often lead to large changes in theusage of medication

Following hospitalization, up to 40% of medications used at admission are not continued atdischarge and up to 45% of medications prescribed at discharge are medications first prescribedto the patient during their hospitalizations (Beers et al, 1989, USA)

14.1% of patients (>65, community dwelling after hospital discharge) experiences 1 or moremedication discrepancies post discharge in comparison to the pre- and post-hospitalmedication regimen, of which 50.8% are identified as patient-associated (Coleman, 2005, USA)

49.8% of 212 elderly patients experienced in hospital modifications of medication regimen– An in hospital modification rate of 50% or higher significantly increased the risk for mortality(Mansur, 2008, USA)

70.7% of patients discharged to home experienced at least one actual or potentialunintentional medication discrepancy, of which the most common unintentional discrepancywas an incomplete prescription at discharge requiring clarification (Wong, 2008, USA)

45

EXAMPLE STUDIES

2 Care Continuity


Pharmacist interventions aim to clarify post discharge medicationand ensure correct utilization

46

2 Care Continuity

Pharmacist-Led Continuity of CareActivities in the Hospitalization Process

Monitor medication Provide medicationsummary

Provide ADEshistory

Informed ontreatment byspecialist/GP

Appropriateness ofmedication check

Development ofcare plan

Patient counselling Patient education Discrepancy check Discharge

medicationsummaries

Synchronisation ofmedication forsimilar period oftime

Medication intakescheme

Proactive follow upthrough– Patient Home

visits– Telephone calls

ILLUSTRATIVE

Specialist

Pharmacist

ClinicalPharmacist

Post-DischargeDischargeTreatmentAdmissionPre-Admission


Pharmacist led continuity of care interventions have shown tosignificantly improve appropriateness of medication

47

Gallagher(2011) 10.00

Crotty(2004b) 3.20

Summated Medication Appropriateness1) Study Population Methodology

2 Care Continuity

110 adult patients transferredfrom hospitals to long termresidential care in Australia

mean age 82.7 Average 7 medications at

admission

Assessed impact of a pharmacisttransition coordinator for olderadults at hospital discharge

Intervention included transfer ofmedication summaries and caseconferences with GP

382 hospitalized patients inIreland

Age >65 years ~70% of patients

polypharmacy

Determine the effect ofSTOPP/START criteria oninappropriate prescribing forelderly patients

Recommendation of(dis)continuation of medicationprovided to physician

Post InterventionPre Intervention

3.00

2.50

Vs. Worsening scorein control group

Vs. Worsening scorein control group

1) Selection based on Cochrane review by Patterson (2012) on interventions to improve appropriate use of polypharmacy , data shown for intervention group only2) Geriatric Evaluation and ManagementNote Medication Appropriateness Index based on 10 dimensions to determine in appropriate prescribing; decrease in summated score indicates improvement in medicationSource: Crotty (2004b), Spinewine (2007), Hanlon (1996), Patterson (2011)


Pharmacist led continuity of care interventions reduce preventableadverse drug events after discharge

48

Dudas (2001) 19%

Forster (2003) 19%

Paulino (2004) 23%

Lipton (1992)1) 88%

Post Discharge ADEs% of Patients Experiencing ADEs

Reduction in ADRs Post Discharge

Schnipper et al. (2006) identified adversedrug events during and afterhospitalization in a group of 178 patientsdischarged from the general medicinesservices

Patient in the intervention group receivedpharmacist counselling at discharge anda follow-up telephone call 3-5 days later

Comparing trial outcomes 30 days postdischarge, preventable ADEs weredetected in 11% of control group patientsvs. 1% intervention patients (p=0.01,unadjusted Odds Ratio 0.10)

2 Care Continuity

1) Geriatric Patient GroupSource: Booz & Company analysis


Continuity of care services have a savings potential of €105–160MN by reducing re-hospitalization and primary care visits

49

105-160 MN

Prevention ofPrimary Care Contacts

~0-10 MN

Prevention ofHospitalizations

105-150 MN

Total Potential Cost Savings

Total Savings Care ContinuityIn € MN

A B

2 Care Continuity

Source: Booz & Company analysis


Avoidance of re-hospitalizations potentially yields a total €105–150MN savings

50


€105–150 MN

Total # Re-Hospitalizations

64,408

# Re-HospitalizationsElderly28,652

Total # ElderlyHospitalizations

651,1871)

% Re-HospitalizationsElderly4.4%2)3)

Total # Non-ElderlyHospitalizations

1,191,8601)

% Re-HospitalizationsNon-Elderly

3.0%2)

# Re-HospitalizationsNon-Elderly

35,755% Reduction Re-Hospitalizations

43%

Cost PerHospitalization€3,816–€ 5,461

Average Cost PerHospitalization4)

€457-€654

X

Average Days ADRHospitalization5)

8.35

X

X

+

X

A Hospitalizations

1) CBS Statline 20112) RIVM, Essink-Bot (2009)3) Rehospitalization defined as clinical hospitalization within 30 days post discharge4) Referentie prijzen CVZ, Leendertse (2008)5) Beijer (2002), Leendertse (2008)Source: Booz & Company Analysis


Pharmacist are effective in reducing re-hospitalizations post-discharge

51

-31

1

11

34363840

586262

87

Dudas(2001)

Bellone(2010)

Shaw(2000)

Crotty(2004)

Schnipper(2006)

Walker(2009)

Holland(2005)

Nazareth(2002)

Stowasser(2002)

Spinewine(2007)

Naunton(2002)

Re-Hospitalization RiskReduction in % per Patient


A Hospitalizations

WeighedAverage

43%

Source: See graph, Booz & Company analysis


178 patients discharged home fromlarge teaching hospital in US

Mean age 60 years Average 8 medications at discharge

Identified DRPs during / after hospitalizationsand determine the effect of pharmacist followup

Intervention included counselling at dischargeand follow up call 3-5 days later

1

110 adult patients transferred tolong term residential care inAustralia

mean age 82.7 Average 7 medications at admission

Assessed impact of a pharmacist transitioncoordinator for older adults at hospitaldischarge

Intervention included transfer of medicationsummaries and case conferences with GP

1

97 patients discharged from 3 acuteadmission psychiatric wards inScotland

No further information available

Evaluated effect of pharmacy dischargeplanning on discharge of mental health patients

Intervention incl. sending discharge plan tocommunity pharmacist / home visits at 1, 4 and12 weeks

1

131 patients discharged patients inAustin, Texas

Mean age 47 years > 3 prescription medicines

Determined effect of a pharmacist consultationon hospital readmissions rates 60 days postdischarge 1

221 general medical service patientat teaching hospital in SanFrancisco

Mean age 54 years No info on disease condition

Studied impact of pharmacist involvement indischarge planning on healthcare utilization

Intervention included sharing discharge plansend to community pharmacist and follow upcall from pharmacy within 2 days of discharge

2

Details on re-hospitalizations (1/2)

52

Crotty (2004) 62%

Schnipper (2006) 87%

Dudas (2001) 40%

Bellone (2010) 58%

Shaw (2000) 62%


Study Population Intervention

A Hospitalizations

Weight1)

1) Weight calculation based on location of intervention and sample sizeSource: See graph, Booz & Company analysis


120 patients in Australia > 60 years, > 4 regular medications >2 chronic medication conditions

Evaluated impact of pharmacist-conductedfollow-up at home of high-risk elderly patientsat 5 days post-discharge 1

624 patients discharged to home in US Mean age 58 years High risk for medication problems

Reviewed medication discrepancies at hospitaldischarge and tested effect of pharmacistintervention on healthcare utilization

Intervention included a follow up call2

203 patients in acute GeriatricManagement and Evaluation unit (BE)

Age >70 years Avg. 9.8 daily drug administrations

Evaluated the effect of pharmaceutical careprovided in addition to acute Geriatricmanagement and evaluation during and postdischarge

2

240 patients discharged from medicaland surgical wards to community in twoAustralian hospitals

No additional information available

Researched the effect of pharmacistintervention on unplanned re-admissions

Intervention included sharing discharge planwith GP/ community pharmacist

1

362 patients discharged from 3 generaland 1 long stay hospital in UK

Age >75 years >4 medication

Investigated effectiveness of pharmacydischarge plan in elderly hospitalized patients

Intervention included discharge plan plusdomiciliary follow up by community pharmacist

2

872 patients discharged from emergencyadmission in UK

Age >80 years Avg. 6 daily drugs at admission

Determined effect of home based medicationreview by pharmacist on hospital readmissionsrates among older people 2

Details on re-hospitalizations (2/2)

53

Holland (2005) -31%

Nazareth (2002) 1%

Stowasser (2002) 11%

Spinewine (2007) 34%

Walker (2009) 36%

Naunton (2002) 38%

A Hospitalizations


Study Population Intervention Weight1)

1) Weight calculation based on location of intervention and sample sizeSource: See graph, Booz & Company analysis


A reduction in post-discharge primary care contacts could yieldsavings of approximately ~€5 MN

54

B Primary Care


~€5 MN

# of Patients WithLikely ADE-RelatedPrimary Care Visit

Post Discharge61,500

Total #Hospitalizations

1,843,0471)

% PatientsExperiencing ADEs

After Discharge26%

% Reduction inPatients With ADEs

Post Discharge91%3)

% of ADR PatientsLikely to VisitPrimary Care

13%2)

Cost of Doctor VisitPer Patient

€774)

X

X

1) CBS Statline 20112) Westerlund (2009)3) Schnipper (2006)4) CVZ total costs of GP visit per “verzekerde” excl. “inschrijfgeld”Source: Booz & Company Analysis



55




Non-Adherence Rate to Medical RecommendationsResults from 2004 Meta Analysis of International Adherence Studies

High non-adherence rates to medical therapy is a common andstubborn problem

56

0 5 10 15 20 25 30 35 40 45 50 55

OB-GYN

Infectious DiseaseEye DisordersRenal Disease

Pulmonary Diseases

DiabetesSleep Disorders

%HIV Disease

Arthritis

Gastrointestinal Disorders

CancerSeizures/ Brain Disorders

Genitourinary & STDs

Skin Disorders

Cardio Vascular DiseasesENT and Mouth Disorders

Blood Disorders1

Average Lower Higher 95% Confidence Bound

# ofStudies Example Conditions

16 Sleep Apnoea

23 Diabetes I, II and III

41 Asthma, CF, COPD

20 Renal Transplant

15 Glaucoma

34 TB, Celiac Disease, Malaria

19 Pregnancy, Breast abn.

7 Cholesterol

30 Otitis Media, Strep Throat

129 HBP , MI, Angina, Bypass

11 Burns, Actinic Keratoses

17 Herpes, Incontinence

9 Seizure, Epilepsy, Stroke

65 Breast, Lung, Leukaemia

42 PUD, H. Pylori

22 RA, Rheumatic Fever

8

Average

3 Therapy Adherence

1) Excluding leukemiaNote: Definition of Non-Adherence differs per studySource: DiMatteo (2004), Booz & Company & Bertlesmann Foundation


Interventions to improve adherence can result in healthimprovement and cost benefits

57

Adherence Can be Improved Higher Adherence is Associatedwith Better Health Outcomes

Higher Adherence is OftenAssociated with Lower Costs

Depression education increasedmedication adherence from 33%

to 66%

Electronic prescriptions led to 10-15% lower non-pick up rates ascompared to paper prescriptions

for diabetes and hypertension

Pharmacist interventionsimproved medication adherence

by 15-20%

Education sessions improvedadherence for hypertensive

patients by 37% and reduced bloodpressure by 20-25 mm

Self-management sessions aboutasthma education and attack

management reducedhospitalizations by 90%

Coaching & patient networksreduced hospitalization for

diabetes by 44%

Higher adherence reducesaverage health care expenditures/

year for diabetes by up to 50%

Annual total care spend forhypertension for adherent patients

was $3,800 lower than non-adherent patients

Education sessions on medicationadherence and methods to prevent

asthma attacks reducedemergency room visits costs per

person per year by 60%

ILLUSTRATIVE

3 Therapy Adherence

Source: Booz & Company & Bertlesmann Foundation


Pharmacist-led disease programs aim to improve medicationutilization and adherence through a wide range of interventions

58

Pharmacist Role In Adherence

Importance ofAdherence

What CanPharmacists

Do?

Adherence to medication therapy is essential to reach therapeutic goals Medication adherence is especially relevant for those patients diagnosed

with chronic diseases and thus largely dependent on chronic medication

In the chain of healthcare providers, the pharmacy has is well positionedto detect problems concerning the chronic use of medication (van Wijk,2005)

Hence, pharmacist could engage in multiple interventions to improveadherence, potentially as part of disease programs, through

– Education (e.g. focussing on self management)– Monitoring– Proactive follow up (e.g. home visits/telephone calls)– Counselling (advanced vs. non-advanced)– Optimization of packaging (e.g. Bextering)

3 Therapy Adherence


Disease programs led by pharmacists can be effective inimproving therapy adherence

59

Elliot(2008)

16%

11%

Murray(2007)

8%

Park(1996)

Chabot(2003)

9%

Weinberger(2002)

0%

Barnett(2000)

1%

Grant(2003)

1%

Berringer(1999)

2%

Bouvy(2003)

4%

McKenney(1978)

19%

Volume(2001)

19%

McKenney(1973)

37%

Jarab(2011)

39%

Therapy Adherence% Improvement Resulting From Pharmacist Interventions

Average13%

Non-Disease SpecificHeart PatientsDiabetesAsthma/COPD

3 Therapy Adherence


Details on Studies (1/2)

60

COPD Patients

127patients in Jordan Mean age 63 years Adherence measured as self-reported

adherence on 4 point Morisky scale

Structured COPD education program incl.education summary booklet

6- month follow up during scheduled visit

HypertensionPatients

49 US patients Mean age 60 years Adherence as % of doses taken

Monthly visits for 5 months, monitoring,counselling, contact with prescribers andeducation; Follow up at 12 months

Patients With > 2Medications

336 patients in Canada Mean age 73.5 years Adherence as avg. % of dose taken

6 telephone calls per month, education,counselling, monitoring

Follow up at 12-13 months


136 US patients Mean age 53.5 years Adherence as avg. % of dose taken

Counselling during refill of medication,monitoring, education

Follow up at 4 months

Heart Failure Patients

314 patients with HF in United States Mean age 62 years Adherence as % of prescribed medication

taken

Review of medication history, medicationeducation and assessment of medicationcompliance


53 US patients Mean age 60 years Adherence as avg. % of dose taken

3 monthly visits with BP and HRassessments, lifestyle counselling anddrug therapy; Follow up at 3 months

Park(1996) 11%

Murray(2007) 16%

McKenney(1978) 19%

Volume(2001) 19%

McKenney(1973) 37%

Jarab(2011) 39%

Therapy AdherenceImprovement in %

Study Population InterventionPatient Group

3 Therapy Adherence


Details on Studies (2/2)

61


100 patients in Canada at 9 community pharmacies Equal distribution across age classes Adherence as % of patient adherent

Encouragement and rewards for goodadherence; recommendations tophysician if needed

Newly PrescribedMedication for

Chronic Patients

500 US patients >75 years or chronic patients Self reported non-adherence defined as having

missed at least one dose in last 7 days

Proactive telephones patients 2 weeksafter starting new medication

Heart Failure Patients 152 patients with heart failure in NL Mean age 70 years Adherence as # of days with medication

Monthly consultations from communitypharmacist focussed on compliance

Type1 or 2 DiabetesPatients

Pharmacist telephones patients 2 weeks afterstarting new medication

Adherence as avg. % of dose taken

pharmacist telephones patients 2weeks after starting new medication

Type 2 Diabetes

120 participants selected from community healthcentre

Adherence as # adherent days past week

Tailored education to reduce self-reporting barriers; outcomes ofintervention reported to primary carephysician

First DescriptionChronic Medication

47 US patients Mean age 46 years Adherence as avg. % of dose taken

Incorporated written questions ofpatients into counselling

Follow up at 5 days

Asthma / COPDPatients

314 US patients Mean age 62.5 years Adherence based on a scale of 4

Counselling at refill and education Follow up at 12 months

Weinberger(2002) 0%

Barnett(2000) 1%

Grant(2003) 1%

Berringer(1999) 2%

Bouvy(2003) 4%

Elliot(2008) 8%

Chabot(2003) 9%

3 Therapy Adherence

Therapy AdherenceImprovement in %

Study Population InterventionPatient Group


Increased adherence will typically lead to higher medication cost,but lower hospitalizations rates

62

MedicationCost ($)

Adherence Level (%)

HospitalizationRisk (%)

80-10060-7940-5920-39<19

Adherence vs. Hospitalization RiskEXAMPLE STUDY US

Diabetes

40-5920-39<19


MedicationCost ($)

Adherence Level (%)80-10060-79

Hypertension

MedicationCost ($)

Adherence Level (%)80-10060-7940-5920-39<19


Hypercholesterolemia

Adherence Level (%)

MedicationCost ($)


80-10060-7940-5920-39<19

Congestive HF

Medication Cost Hospitalization Risk

3 Therapy Adherence

Note: Adherence calculated as % days supply / 1 yearSource: Sokol (2005), Booz & Company analysis


Also in a pharmacist-led program, the increase in medication costcan be offset by a decrease in healthcare utilization cost

63

723

56

647

88

1,017

52

853

82

PrescriptionCost

+6

-206

+4

-293

TotalCost

PrescriptionCost

TotalCost

Intervention Control

Mean Cost Results$ Per Patient, Per Month

Controlled for Disease SeverityNot Controlled for DiseaseSeverity

Effect of Pharmacist Intervention

Studied effect of pharmacist interventions incommunity retail setting for patients withhypertension, diabetes, asthma orhypercholesterolemia

Intervention included specialized training forpharmacist, patient education, performingsystematic monitoring, offering feedback,behaviour modification and communicatingregularly with patients’ GP

118 patients with mean age 67.2 at 3 interventionvs. 401 patients in the control group (mean age63.3)

Economic effect determined based on comparisonof prescription and total medical utilizationcost based on billed charges as a proxy for cost

Results indicated savings of $206-$293 totalmedical costs per patient per month, althoughaverage cost per prescription were significantlyhigher in the intervention group

EXAMPLE STUDY US

3 Therapy Adherence

Source: Munroe (1997), Booz & Company analysis


Several studies report a positive cost-benefit for increased levels ofadherence

64

Cost-Benefit Increased AdherenceSokol (2005) vs. Roebuck (2009)

Diabetes7.1 .1

5.1 : 1Hyper

cholestorolmenia

6.7 : 1

Hypertension

3.1 : 1

4.1 : 1

10.1 : 1

RoebuckSokol

Details on StudiesSokol (2005) vs. Roebuck (2009)

Sokol (2005)

Roebuck(2009)

Conducted cost benefit analysisbased on medical cost related toheart failure

224 131 patients with 1 or morechronic vascular condition

Increase in pharmacy costs isoffset by substantial medicalsavings

Evaluated the impact ofmedication adherence onhealthcare utilization and cost

Population based sample of137,277 patients < 65 years

Increase in adherence providesnet economic return for selectedchronic conditions

ILLUSTRATIVE

3 Therapy Adherence


Also adherence programs for asthma have demonstrated high ROIratios

65

Medical Benefits to Medical Costs Ratio for Asthma Outcome Driven by Adherence

Single outreach nurse program reduced emergencydepartment visits and hospitalizations among thosewho had been hospitalized previous year by 50%

Education sessions reduced emergency wardadmissions by 79% and hospital admissions by 86%

Self-management sessions reduced the number ofdays on which the activity of participants was limitedby 35%

Self-management sessions produced net benefits incost savings

Single outreach nurse program reducedhospitalizations and work absences

A

B

C

D

E

A

B

C

D

E Ohio Study 2:1

Germany Program 5:1

Henry Ford 7:1

Harvard Plan 8:1

Open Airways 11:1

ILLUSTRATIVE

3 Therapy Adherence

Source: Adherence to long term therapies, evidence for action WHO 2003: Multiple studies from various researchers aggregated by WHO, Booz & Company Analysis


Disease Programs

Patient EducationFocused on Self-

Management

Optimized Packagingto Simplify MedicationTherapy Management

for Patient

Proactive Follow-Upon Therapy Adherence

Via Home Visits/Telephone Calls

Therapy /MedicationAdherence

HealthcareUtilizations- Primary Care- Hospitalizations- Policlinic Care

Medication Costs

We calculate the potential savings resulting from improvedtherapy adherence as a result of disease programs

66

Effect of Disease Programs Quantification Method

Pharmacist interventions have adirect effect on improving therapyadherence for chronic diseasepatients

Therapy adherence is an importantdeterminant of the success ofmedication therapy – strongadherence has shown to decreasehealthcare utilization cost andincrease patient productivity

This relationship is frequentlydefined for a specific patient group– diseases to investigate areselected based on

– Medication cost per disease(Cost of Illness, RIVM)

– Healthcare utilization perdisease (CBS)

– Most prevailing diseases (CBS)

Clinical Outcome€ Outcome

Example Levers forIncreased Adherence

3 Therapy Adherence


We selected diseases for quantifying adherence potential based onmedication intensity, share of total medication cost and prevalence

67

% MedicationCost / Total

Therapy Costs

PatientGroup

SelectionPrevalence

ChronicCondition

Selection Criteria Patients GroupsQuantification of Improved Adherence Potential

% MedicationCosts

Understand the importance / cost ofmedication in overall therapy

Determine point of gravity in termsof healthcare providers

Understand the spread ofmedication costs over diseasecategories

Determine which diseases haverelatively high medication costs

Understand which diseasesrequire chronic medicationtherapy

Understand the prevalence ofdifferent chronic diseases

3 Therapy Adherence


We have looked at 5 disease groups

68

% Medication / Total Cost

% Medication Cost

Other

Pregnancy, childbirth and the puerperium

Not allocated / Not disease related

Diseases of the blood and blood-forming organs

Diseases of the digestive system

Mental and behavioural disorders

Diseases of the skin and subcutaneous tissue

Infectious and parasitic diseases

Neoplasms

Symptoms / incomplete diagnoses

Diseases of the genitourinary system

Diseases of the musculoskeletal system and connective tis

Diseases of the circulatory system

Diseases of the respiratory system

Endocrine,nutritional and metabolic diseases

Diseases of the nervous system

Selection of Disease Categories

3 Therapy Adherence

Medication Intensity of the Therapy

Share of totalMedicationCost inNetherlands

Selection of Diseases


Medication costs are evenly distributed across disease categories –the 5 highest categories account for ~60% of medication cost

69

Medication Cost Per Disease Category1)

In € MN, per Sector

140143164231

365416

483509510590

675781

851

1,330

1,451

Total cost of medicationand medical aid materials

are 8,6 BN in 2007, ofwhich ~50% is issued bycommunity pharmacies

3 Therapy Adherence

BACK-UP


1) Medication cost include “medical aid materials”, such as contacts, glasses etc.Source: Kosten van Ziekten 2007 volgens Zorgberekeningen CBS, Booz & Company analysis


The importance of medication as cost component differs acrossdisease categories

70

Cost Per Disease Category1)

In € MN, per Sector

3,981

36%

6,911

19%

50%

100%3,046

5%

1,555

9%

802

20%

1,064

22%7%

17,615

2%

1,907

25%

15,895

3%

3,423

15%

4,094

14%

2,618

26%

1,707

46%

4,950

17%

4,879

Medication/Medical AidOther Care

3 Therapy Adherence

BACK-UP


1) Medication cost include “medical aid items”, such as contacts, glasses etc.Source: Kosten van Ziekten 2007 volgens Zorgberekeningen CBS, Booz & Company analysis


For these categories, we determine the importance of individualdiseases – a selection of 5 diseases is made for our analysis

71

Multiple sclerosis

Parkinson’s disease

% Medication / Total Cost

Osteoporosis

Neck and back painOsteoarthrosis

Rheumatoid arthritis

Heart failure

Coronary heart disease

Hypertension

Asthma / COPD

Diabetes

Ear disorders

Disorders of accommodation and refraction

Epilepsy

Selection of Disease CategoriesSize of the Bubble Indicate Total Costs in the Netherlands)

3 Therapy Adherence

Medication Intensity of the Therapy

Share of TotalMedicationCost inNetherlands

Mostlymechanical

aids

BACK-UP



Selection of diseases – details

72

Disease Category Disease Include/Exclude Rationale

Diseases of the NervousSystem

Multiple sclerosis Medication most important driver of total cost However 75% of cost is driven by medical aid items

including– Contact Lenses– Glasses– Hearing Aid

Parkinson's disease

Epilepsy

Disorders of accommodation andrefraction

Ear disorders

Endocrine, Nutritionaland Metabolic Diseases Diabetes

Diabetes accounts for 78% of medication cost withindisease category

58% of Diabetes disease cost allocated to medication

Diseases of theRespiratory System Asthma /COPD

Medication as primary treatment Asthma / COPB together account for 68% of

medication/medical aid cost within disease category

Diseases of theCirculatory System

Hypertension 44% of medication cost within disease category related

to Hypertension Hypertension mainly treated through medication

Coronary Heart diseases

Heart failure

Diseases of theMusculoskeletal Systemand Connective Tissue

Rheumatoid arthritis 40% of total disease category cost related to

secondary care; only 17% to medication Rheuma accounts for 33% of medication costs for

entire disease category, as 50% of its cost are relatedto medication

Osteoarthrosis

Neck and back pain

Osteoporosis

3 Therapy Adherence

BACK-UP


1) Medication cost as % of total cost per diseaseSource: Kosten van Ziekten 2007,Booz & Company analysis


Increased adherence could yield €250–400 MN in net savingsthrough reduction of healthcare utilization and medication costs

73

Medication Cost

Hospitalization

Primary Care

Net CostSavings

250-400 MN

-200

380-530

~70

Increase inmedication cost

120

SavingsPotenial

80-195

60-175

20

Increase inMedication Cost

Increase inMedication Cost

70

SavingsPotenial

~ 300-350

~290

35

SavingsPotenial

50-80

35-6515

10

Net Savings Therapy Adherence Focused Disease ProgramsIn € MN

A B C

Heart Diseases Diabetes Asthma/COPD

3 Therapy Adherence

Note: Medication cost calculated by multiplying the % increase in adherence as reported in studies per disease with annual medication cost (Kosten van Ziekten, 2007)Source: Booz & Company analysis


Medication adherence has a significant effect in reducing thenumber of hospitalizations for heart patients

74

Adherence notdirectly measured

83 patients in Northern Ireland Patients aged > 65 years Hospitalized or clinic attendance for HF

Pharmaceutical care program incl.education on disease / treatment, lifestylechanges, encouragement for compliance


97 patients in Australia; avg. 75 years High risk patients hospitalized for HF and

discharged to community

Home visit of multidisciplinary team (incl.nurse) to determine medicationcompliance 7-14 days after discharge

41%1) 208 patients with mild/moderate HF Recruited from outpatient clinics Mean age 58 years

Pharmacist led care program focussingon intensive education and self-monitoring

4%1) 152 patients with HF using loop diuretics Presented to cardiology outpatient clinic /

admitted to hospitals in NL; Mean age 70

Intervention incl. monthly consultationsfrom community pharmacist focussing onmedication education / compliance ass.

16%2) 314 patients with HF in United States Mean age 62 years Presented to single primary care group

Intervention incl. review of medicationhistory, medication education andassessment of medication compliance=


154 US patients discharged fromhospital with HF diagnosis

Mean age 80; home care receiving

Intervention based on clinical pharmacisthome visits focussed on assessment ofmedication compliance

0% 276 patients hospitalized with HF in

Canada discharged to community Mean age 72 years

Intervention consisted of education self-monitoring, adherence aids, newsletters,telephone hotline and proactive follow up

All Cause HospitalizationsReduction in %


15%

Tsuyuki(2004) 3%

Triller(2007)

74%Varma(1999)

Stewart(1998)

Sadik(2005)

Bouvy(2003)

Murray(2007) 19%

20%

38%

47%

Impact onadherence

Range 15-25%

A Heart Diseases

1) Adherence calculated as # of days without medication2) Adherence calculated as % of prescribed medicationSource: Booz & Company analysis


Hence, increased adherence could lead to a significant costreduction of ~€300-350 MN

75

Total Cost Savings~€325 MN

Reduction #Hospitalizations

~30,700

Reduction inHospitalizations as

Result of Adherence15–25%

# of AnnualHospitalizations Heart

Diseases1)

340,000

Cost of SecondaryCare Per

Hospitalization~€9,400

/Cost of

Secondary CareSelected Diseases3)

€1,461 MN

X% HospitalizationsRelated to Selected

Diseases2)

46%

X

# of AnnualHospitalizationsSelected Heart

Diseases4)

~156,000

Total Cost SavingsSecondary Care

~€290 MN

Total Cost SavingsPrimary Care

~€35 MN

Cost of PhysicianVisits for Heart

Diseases3)

€233 MNReduction in VisitsDue to Increased

Adherence5)

15%

X

+

A Heart Diseases

1) CBS Statline 20072) Calculated as cost of secondary care for selected heart diseases / total cost of secondary care for heart diseases3) Kosten van Ziekten, RIVM/Erasmus Universiteit 20074) Total # of hospitalizations * % related to selected diseases (46%)5) Tsuyuki (2004)Source: Booz & Company analysis


Medication adherence has a significant effect on the number ofhospitalizations for diabetes patients

76

Impact measured ofrelatively high non-adherence versusrelatively low non-adherence 1)

900 US enrolees from managed careorganization

Patients aged >18 years with type 2diabetes

Tacking anti-diabetes medication, butnot taking insulin

Analysis of association betweenmedication non-adherence andsubsequent hospitalization amongindividuals based on administrative claimsdata

Study duration one year

Impact measured ofrelatively high non-adherence versusrelatively low non-adherence 2)

11 532 US patients with diabetesmellitus in a managed care organization

Mean age 64 years

Retrospective study to assess theassociation of medication non-adherence

Adherence calculated as proportion ofdays covered for filled prescriptions


Impact measured ofrelatively high non-adherence versusrelatively low non-adherence

Population based sample of 3260 USpatients < 65 years old

Mean age 53.9 years

Evaluation of impact of medicationadherence on healthcare utilization

Retrospective cohort observation usingadministrative claims data

Study duration 2 years

Impact measured ofrelatively high non-adherence versusrelatively low non-adherence

57,687 US diabetes patients < 65years, 90% aged 40 years

Continuously enrolled with medical anddrug eligibility

Varying disease severity

Analysis of adherence impact on well-being and health care costs

Retrospective cohort design usinginsurance claims




31%

Ho (2006) 58%

Hepke (2006) 24%

Sokol (2005)

Lau (2004) 61%

Impact onadherence

Range24%-43%

B Diabetes

1) Adherence as independent variable to explain variation in hospitalizations (not direct study outcome), calculated as Medication possession ratio (MPR)2) Adherence as independent variable to explain variation in hospitalizations (not as outcome), calculated as proportion of days covered for filled prescriptionsSource: Booz & Company analysis


Increased medication adherence for diabetes patients can deliversignificant cost potential of €50–80 MN

77

Reduction # DiabetesHospitalizations

~9,500


Result of Adherence24%–43%

# of AnnualHospitalizations

Endocrine Diseases1)

53,123

Cost of SecondaryCare per


/

Cost of SecondaryCare Diabetes

€146.3 MN

X% Hospitalizations

Related to Diabetes 2)

41%

X


Diabetes3)

~21,800


~€35–65 MN


~€15 MN

Cost of PhysicianVisits for Diabetes 4)

€137.4 MN

Reduction in VisitsDue to Increased

Adherence5)

11%

X

Total Cost Savings~€50–80 MN +

B Diabetes

1) CBS Statline 20072) Calculated as cost of secondary care for diabetes / total cost of secondary care for endocrine diseases3) Total hospitalizations endocrine diseases * % related to diabetes (41%)4) Kosten van Ziekten, RIVM/Erasmus Universiteit 20075) Wagner (2001)Source: Booz & Company analysis


A reduction in diabetes related complications could yield another€150 MN (not included in this assessment)

78

Total Opportunity

200-230

Reduction DiabetesComplications

220

~ 1502)

50-80 MN

Primary Care Total Potential CostSavings

15 MN

Hospitalization

35-65 MN

Potential Savings DiabetesIn € MN

As Presented in Diabetes Study1)

ILLUSTRATIVE

B Diabetes

1) Novo Nordisk Diabetes study conducted by Booz & Company2) € reduction of other complications calculated based on1,3 BN cost of complications * 24% reduction * 50% realization factorSource: Booz & Company analysis


Medication adherence significantly reduces the number ofhospitalizations for Asthma/COPD patients

79


53 patients, age 1-17 Ambulatory patients of HMO with 70%

inner city black population

Asthma outreach program by nurse (8hours per week) maintaining personal /phone contact with families on reg. basis

39%

127Jordan patients >35 years patientsrecruited from outpatient COPD clinic

On average 8 medications Adherence measured as self-reported

adherence on 4 point Morisky scale

Structured COPD education program byclinical pharmacist, incl. educationsummary booklet, 6-month follow upduring scheduled visit

12% increase ofMedication

76 US patients with moderate tosevere asthma; disease generallyunder medical control

Average age 49.8 years

Education program consisting of 7x 90min sessions with group leaderpresenting and discussing topics incl.medication and management

Impact measured ofhigh versus low

non-adherence 1)

405 US adults age 18–50 years; meanage 36.6 years

Members of HMO in Michigan

Retrospective study estimating theproportion of poor asthma-relatedoutcomes attributable to ICS non-adherence


185 US adults between 18 - 70 years,mean age 37 years

Recruited from urban and sub-urbanemergency room

Self management program consisting of33 educational sessions stressingimportance of medication compliance,effects of drugs, attack management etc.



63%Kotses(1995)

22%Bolton(1991)

60%

Jarab(2011) 72%

Greidener(1995) 86%

Williams(2004)

Impact onadherence

Range22- 63%

C Asthma/COPD

1) Adherence not included as primary outcome of study, but as independent variableSource: Booz & Company analysis


Medication adherence could lead to a significant cost reduction of€80–195 MN

80


~€60–175 MN

Reduction #Hospitalizations12,000–34,000


Result of Adherence22%–63%


Airways1)

196,745

Cost of SecondaryCare Per


/

Cost of SecondaryCare Selected

Diseases4)

€277.6 MN

X

% HospitalizationsRelated to Selected

Diseases2)

27%

X

# of AnnualHospitalizationsAsthma/COPD3)

~54,040


~€ 20 MN

Cost of PhysicianVisits for

COPD/Asthma3)

€87.80 MN

Reduction in VisitsDue to Increased

Adherence5)

20%

Total CostSavings

~€80–195 MN

X

+

C Asthma/COPD

1) CBS Statline 20072) Calculated as cost for asthma/.COPD secondary care / total cost for Airways diseases secondary care3) Total hospitalizations airways diseases * % related to diabetes (27%)4) Kosten van Ziekten, RIVM/Erasmus Universiteit 20074) Bolton (1991), Kotses (1995)Source: Booz & Company analysis


For the selected extra medication costs associated with increasedadherence are substantially lower than the savings potential

81

~ 325 MN

1,080 MN

605 MN

50-80

HeartDiseases

11%

30%

30%

Asthma /COPD

454 MN

80-195 MN

Diabetes

Medication CostSavings Potential

Savings Potential vs. Medication CostIn € MN

Potential as % ofMedication Cost

BACK-UP

Note: Medication cost include “medical aid supplies”Source: Kosten van Ziekte RIVM/Erasmus University 2007, Booz & Company analysis



82


International Context


Professional pharmaceutical services have been widelyimplemented in the international context

83

Pharmaceutical services offered byprivately-owned communitypharmacies on (limited)reimbursement by health insurances

Services formalized underMedication TherapyManagement for Medicarebeneficiaries, a subset of high-cost patients Pharmaceutical services negotiated

under the “Family PharmacyContract” in 2004 securingremuneration for pharmacist

Three-tier type of services offered byprivately-owned communitypharmacies under contract byNational Health Service (NHS)

Pharmaceutical care heavilyregulated with a small number oflarge services providing a limitednumber of value added services

Pharmaceutical care services as keycomponent of the healthcare system,with funding for a wide range ofservices outside of dispensing

Pharmaceutical Professional Services Around the WorldILLUSTRATIVE


Remuneration for Pharmaceutical professional services dependson country specific factors

84

Method ofRemuneration

Quality / LayOut Standards

LegalFramework

Scope ofRemuneration

ProfessionalPharmaceutical

Services

Remuneration for Pharmaceutical Professional ServicesCountry Level Drivers

PPS usually not legally mandatedexcept for patient counselling (i.e.providing information)

Some countries include PPS asstandard service obliged by law

Different methods of serviceremuneration exist, e.g. throughgovernment, health insurers andpatients

Difference between reimbursement forservices related to OTC andprescription medicine

Majority of countries remunerate PPSonly when medicine is paid underreimbursement

Required quality assessment caninclude staff / patient satisfactionand performance assessment

Some countries require specificareas for private consultation

ILLUSTRATIVE

Source: Bernsten (2010)


In most countries, both government and health insurancecompany’s are involved in negotiating tariffs

85

QualityServices

Medication review Provision of written drug

information Disease programs for

chronic disease patients Therapeutic decision

participation

Medication utilizationadvice

Medication therapyoptimization

Healthy lifestyle advice Disease programs

Three-tier servicestructure with 7 essentialservices to be provided byall pharmacies in tier 1

Medication use advice Measurement of blood

glucose, blood pressureand cholesterol

Inhalation counselling

Services as defined byNZA, incl. medicationreview, education andcontinuity of care

PharmacyDelivery

Privately ownedcommunity pharmaciesunder the AUS communitypharmacy authority

Privately-ownedpharmacy’s (pharmacistonly) with max. 4pharmacies p.p.

Privately ownedcommunity pharmacies

Private communitypharmacies, regulated byhealth authorities (numberand pricing)

Privately ownedpharmacies

Remuneration Remuneration based on

Government’s NationalMedicines Policy (10% ofpharmacy income)

Nationwide contract withlargest health insurancefund (family pharmacycontract)

National Health Services (NHS)

Health authority regulatedmarket with limitedremuneration for services

Differing remuneration dueto individual negotiationwith insurance companies

RemunerationRequirements Not specified

Non-mandatory qualityguidelines on processesfor specific pharmaservices/activities

Remuneration underQuality Assuranceframework as specified byNHS

Not specified Not specified

Scale 5,000 community

pharmacies as keycomponent of healthsystem

Majority of communitypharmacies (>17,000)registered for program

40% accredited formedication reviews(advanced service level)

Approximately 1 pharmacyper 16,700 inhabitants; allproviding services

Not widely adopted acrosspharmacies – limitedoffering and remunerationfor services

Remunerated Pharmacy Services per Country

Selection ofRelevant Countries

Note: US excluded as services offered to specific patient group onlySource: Booz & Company analysis


In the UK, pharmaceutical services are provided through a three-tier structure

86

EssentialServices

AdvancedServices

EnhancedServices

Tier 1 Tier 2 Tier 3

Dispensing – safe supply ofmedication and appliances

Repeat dispensing – management ofrepeat prescription up to 1 year inpartnership with patient/prescriber

Disposal of unwanted medication –safely disposing unwanted medication

Healthy lifestyle promotion –opportunistic one-to-one advice onhealthy lifestyle topics (smoking) topatients collecting medication

Signposting – referral of patient toother healthcare providers

Clinical governance –implementation of system of clinicalgovernance to support provision ofquality care

Medicine Use Review &Prescription Intervention Service –adherence focused medication reviewwith individual patients targeted at– Respiratory disease patients– Hospital discharge patients– Patients on high risk medication

New Medicine (Appliance) Service –provide patient with information ontheir new medicine (appliance) andhow to use it at dispensing with followup by telephone in around a fortnight,and final consultations after 21-28days

Stoma Appliance CustomizationService – ensure proper use andimprove duration of usage

Group of services commissionedlocally by pharmacist based on localneeds of population mostly aimed toimprove public health, examplesinclude– Minor ailments management– Palliative care services– Services to schools– Supplementary and independent

prescribing by pharmacists– Medicines assessment and

compliance support– Sexual health services

Pharmaceutical Care Services – UKEXAMPLE UK


GP – Pharmacist collaboration forms the basis for the German“Family Contract”

87

Family Pharmacy Contract

Trilateral contract between GPs, physicians andinsurance companies; So called “family contract”includes patients choosing their GP and their familypractice

Concept aims to enable direct communication betweenthe community pharmacist and the GP on issuesconcerning drug therapy

Contract includes remuneration for advanced services,such as drug profiles, medication reviews, counsellingand medication reports, for specific diseases such asasthma/COPD

Under this advanced services program, patient choosesGP and family practice for a set term, usually at leastone year

All medication (prescription/OTC) are delivered by theselected pharmacy

Pharmacist qualification for the program occurs througha one day education program; in addition pharmacistneed to be in possession of right software

Health Insurance – Secureadditional benefits/servicesfor their customers atmoderate cost

Pharmacist – Aim tooptimize medicationtherapy management interms of efficiency andefficacy

GP – Optimize prescribingof medication based onindications and patient

medication therapy andhistory

EXAMPLE GERMANY


Australian service remuneration is based on a government issuedmeta analysis of the effectiveness of services

88

Service Evidence for Effectiveness

Pharmaceutical Care Services

Continuity of Care Services Post-Hospital Discharge

Education Services to Consumers

Education Services to Health Practitioners

Pharmacist Managed Clinics

Review of Repeat Prescribing

Pharmacist Participation in Therapeutic DecisionMaking

Administration of Vaccines TBD

Involvement in Pre-Admission Clinics TBD

Participation in Home Services TBD

Overview of Reviewed Services

Meta analysis commissioned bythe Pharmacy Guild of Australia,

funded by Commonwealthdepartment of Health and ageing,

as input for policy / strategicplanning of development of

professional services in Australia

EXAMPLE AUSTRALIA

Source: “The value of Pharmacist Professional Services in the Community Setting, Meta analysis 1990 -2000”, Roughead (2002)



89




References – General

Nkansah N, Mostovetsky O, Yu C, Chheng T, Beney J, Bond CM, Bero L. Effect of outpatient pharmacists' non-dispensing roles on patient outcomes andprescribing patterns. Cochrane Database Systematic Review 2010

Ryan R, Santesso N, Hill S, Lowe D, Kaufman C, Grimshaw J. Consumer-oriented interventions for evidence-based prescribing and medicines use: anoverview of systematic reviews. Cochrane Database Systematic Review 2011

Smith SM, Soubhi H, Fortin M, Hudon C, O'Dowd T. Interventions for improving outcomes in patients with multi-morbidity in primary care and communitysettings. Cochrane Database Systematic Review 2012

Hakkaart-van Roijen L, Tan SS, Bouwmans CAM. Handleiding voor kostenonderzoek, methoden en standaard kostprijzen voor economische evaluaties in degezondheidszorg. College voor zorgverzekeringen. Geactualiseerde versie 2010.

World Health Organization. Adherence to long term therapies, evidence for action. WHO 2003 CBS. Statistics on the prevalence of disease in The Netherlands. 2011 RIVM, Erasmus University Rotterdam. Kosten van Ziekten 2007, versie 1.2, 21 December 2011. Griens A.M.G.F. et al. Data en Feiten 2011. Stichting Farmaceutische Kerngetallen 2011

90


References – Continuity of Care

Bellone JM, Barner JC, Lopez DA. Post discharge interventions by pharmacists and impact on hospital readmission rates. J Am Pharm Assoc (2003);3:358-62.

Crotty M, Rowett D, Spurling L, Giles LC, Phillips PA. Does the addition of a pharmacist transition coordinator improve evidence-based medicationmanagement and health outcomes in older adults moving from the hospital to a long-term care facility? Results of a randomized, controlled trial. Am J GeriatrPharmacotherapy 2004;4:257-64.

Forster AJ, Clark HD, Menard A, Dupuis N, Chernish R, Chandok N, Khan A, van Walraven C. Adverse events among medical patients after discharge fromhospital. CMAJ 2004; Feb 3;170(3):345-9. Erratum in: CMAJ. 2004;5:771.

Holland R, Lenaghan E, Harvey I, Smith R, Shepstone L, Lipp A, Christou M, Evans D, Hand C. Does home based medication review keep older people out ofhospital? The HOMER randomised controlled trial. BMJ 2005;330:293.

Lipton HL, Bird JA. The impact of clinical pharmacists' consultations on geriatric patients' compliance and medical care use: a randomized controlled trial.Gerontologist 1994;34:307-15.

Nazareth I, Burton A, Shulman S, Smith P, Haines A, Timberal H. A pharmacy discharge plan for hospitalized elderly patients--a randomized controlled trial.Age Ageing. 2001;30:33-40.

Naunton, M and Peterson, GM (2003). Evaluation of Home-based Follow-up of High-Risk Elderly Patients Discharged from Hospital. Journal of PharmacyPractice and Research. 2003;33:176-182.

Paulino EI, Bouvy ML, Gastelurrutia MA, Guerreiro M, Buurma H; ESCP-SIR Rejkjavik Community Pharmacy Research Group. Drug related problemsidentified by European community pharmacists in patients discharged from hospital. Pharm World Sci. 2004;6:353-60.

Schnipper JL, Kirwin JL, Cotugno MC, Wahlstrom SA, Brown BA, Tarvin E, Kachalia A, Horng M, Roy CL, McKean SC, Bates DW. Role of pharmacistcounselling in preventing adverse drug events after hospitalization. Arch Intern Med. 2006;166:565-71.

Spinewine A, Swine C, Dhillon S, Lambert P, Nachega JB, Wilmotte L, Tulkens PM. Effect of a collaborative approach on the quality of prescribing for geriatricinpatients: a randomized, controlled trial. J Am Geriatr Soc. 2007;55:658-65.

Shaw, H., Mackie, C. A. and Sharkie, I. Evaluation of effect of pharmacy discharge planning on medication problems experienced by discharged acuteadmission mental health patients. International Journal of Pharmacy Practice, 8: 144–153.

Stowasser, D., Collins, D. M. and Stowasser, M. (2002) A Randomised Controlled Trial of Medication Liaison Services: Patient Outcomes. Journal ofPharmacy Practice & Research, 32 2: 133-140.

Walker PC, Bernstein SJ, Jones JN, Piersma J, Kim HW, Regal RE, Kuhn L, Flanders SA. Impact of a pharmacist-facilitated hospital discharge program: aquasi-experimental study. Arch Intern Med. 2009 Nov 23;169(21):2003-10.

91


References – Medication Review (1/3)

Begley, S., Livingstone, C., Hodges, N. and Williamson, V. (1997), Impact of domiciliary pharmacy visits on medication management in an elderly population.International Journal of Pharmacy Practice, 5: 111–121

Bernsten C, Björkman I, Caramona M, Crealey G, Frøkjaer B, Grundberger E, Gustafsson T, Henman M, Herborg H, Hughes C, McElnay J, Magner M, vanMil F, Schaeffer M, Silva S, Søndergaard B, Sturgess I, Tromp D, Vivero L, Winterstein A; Pharmaceutical care of the Elderly in Europe Research (PEER)Group. Improving the well-being of elderly patients via community pharmacy-based provision of pharmaceutical care: a multicentre study in seven Europeancountries. Drugs Aging. 2001;18(1):63-77.

Bond C, Matheson C, Williams S, Williams P, Donnan P. Repeat prescribing: a role for community pharmacists in controlling and monitoring repeatprescriptions. Br J Gen Pract. 2000 Apr;50(453):271-5.

Crotty M, Halbert J, Rowett D, Giles L, Birks R, Williams H, Whitehead C. An outreach geriatric medication advisory service in residential aged care: arandomised controlled trial of case conferencing. Age Ageing. 2004 Nov;33(6):612-7.

Desborough JA, Sach T, Bhattacharya D, Holland RC, Wright DJ. A cost-consequences analysis of an adherence focused pharmacist-led medication reviewservice. Int J Pharm Pract. 2012 Feb;20(1):41-9.

Furniss L, Burns A, Craig SK, Scobie S, Cooke J, Faragher B. Effects of a pharmacist's medication review in nursing homes. Randomised controlled trial. Br JPsychiatry. 2000 Jun;176:563-7.

Garfinkel D, Mangin D. Feasibility study of a systematic approach for discontinuation of multiple medications in older adults: addressing polypharmacy. ArchIntern Med. 2010 Oct 11;170(18):1648-54.

GRYMONPRE, R. E., WILLIAMSON, D. A. and MONTGOMERY, P. R. (2001), Impact of a pharmaceutical care model for non-institutionalised elderly: resultsof a randomised, controlled trial. International Journal of Pharmacy Practice, 9: 235–241

Hanlon JT, Schmader KE, Samsa GP, Weinberger M, Uttech KM, Lewis IK, Cohen HJ, Feussner JR. A method for assessing drug therapy appropriateness. JClin Epidemiol. 1992 Oct;45(10):1045-51.

Leendertse AJ, Egberts AC, Stoker LJ, van den Bemt PM; HARM Study Group. Frequency of and risk factors for preventable medication-related hospitaladmissions in the Netherlands. Arch Intern Med. 2008 Sep 22;168(17):1890-6.

Leendertse AJ, Van Den Bemt PM, Poolman JB, Stoker LJ, Egberts AC, Postma MJ. Preventable hospital admissions related to medication (HARM): costanalysis of the HARM study. Value Health. 2011 Jan;14(1):34-40.

Holland R, Desborough J, Goodyer L, Hall S, Wright D, Loke YK. Does pharmacist-led medication review help to reduce hospital admissions and deaths inolder people? A systematic review and meta-analysis. Br J Clin Pharmacol. 2008 Mar;65(3):303-16.

92



Krska J, Cromarty JA, Arris F, Jamieson D, Hansford D, Duffus PR, Downie G, Seymour DG. Pharmacist-led medication review in patients over 65: arandomized, controlled trial in primary care. Age Ageing. 2001 May;30(3):205-11.

Krska J, Avery AJ; Community Pharmacy Medicines Management Project Evaluation Team. Evaluation of medication reviews conducted by communitypharmacists: a quantitative analysis of documented issues and recommendations. Br J Clin Pharmacol. 2008 Mar;65(3):386-96.

Lenaghan E, Holland R, Brooks A. Home-based medication review in a high risk elderly population in primary care--the POLYMED randomised controlledtrial. Age Ageing. 2007 May;36(3):292-7. Epub 2007 Mar 26.

Lipton HL, Bird JA. The impact of clinical pharmacists' consultations on geriatric patients' compliance and medical care use: a randomized controlled trial.Gerontologist. 1994 Jun;34(3):307-15.

McMullin ST, Hennenfent JA, Ritchie DJ, Huey WY, Lonergan TP, Schaiff RA, Tonn ME, Bailey TC. A prospective, randomized trial to assess the cost impactof pharmacist-initiated interventions. Arch Intern Med. 1999 Oct 25;159(19):2306-9.

Patterson SM, Hughes C, Kerse N, Cardwell CR, Bradley MC. Interventions to improve the appropriate use of polypharmacy for older people. CochraneDatabase Syst Rev. 2012 May 16;5:CD008165. Review.

Roberts MS, Stokes JA, King MA, Lynne TA, Purdie DM, Glasziou PP, Wilson DA, McCarthy ST, Brooks GE, de Looze FJ, Del Mar CB. Outcomes of arandomized controlled trial of a clinical pharmacy intervention in 52 nursing homes. Br J Clin Pharmacol. 2001 Mar;51(3):257-65.

Royal S, Smeaton L, Avery AJ, Hurwitz B, Sheikh A. Interventions in primary care to reduce medication related adverse events and hospital admissions:systematic review and meta-analysis. Qual Saf Health Care. 2006 Feb;15(1):23-31. Review.

Schmader KE, Hanlon JT, Pieper CF, Sloane R, Ruby CM, Twersky J, Francis SD, Branch LG, Lindblad CI, Artz M, Weinberger M, Feussner JR, Cohen HJ.Effects of geriatric evaluation and management on adverse drug reactions and suboptimal prescribing in the frail elderly. Am J Med. 2004 Mar 15;116(6):394-401.

Sellors J, Kaczorowski J, Sellors C, Dolovich L, Woodward C, Willan A, Goeree R, Cosby R, Trim K, Sebaldt R, Howard M, Hardcastle L, Poston J. Arandomized controlled trial of a pharmacist consultation program for family physicians and their elderly patients. CMAJ. 2003 Jul 8;169(1):17-22.

Sorensen L, Stokes JA, Purdie DM, Woodward M, Elliott R, Roberts MS. Medication reviews in the community: results of a randomized, controlledeffectiveness trial. Br J Clin Pharmacol. 2004 Dec;58(6):648-64. Erratum in: Br J Clin Pharmacol. 2005 Mar;59(3):376.

Spinewine A, Swine C, Dhillon S, Lambert P, Nachega JB, Wilmotte L, Tulkens PM. Effect of a collaborative approach on the quality of prescribing for geriatricinpatients: a randomized, controlled trial. J Am Geriatr Soc. 2007 May;55(5):658-65.

Taylor CT, Byrd DC, Krueger K. Improving primary care in rural Alabama with a pharmacy initiative. Am J Health Syst Pharm. 2003 Jun 1;60(11):1123-9.

93



Trygstad TK, Christensen D, Garmise J, Sullivan R, Wegner S. Pharmacist response to alerts generated from Medicaid pharmacy claims in a long-term caresetting: results from the North Carolina polypharmacy initiative. J Manag Care Pharm. 2005 Sep;11(7):575-83.

Trygstad TK, Christensen DB, Wegner SE, Sullivan R, Garmise JM. Analysis of the North Carolina long-term care polypharmacy initiative: a multiple-cohortapproach using propensity-score matching for both evaluation and targeting. Clin Ther. 2009 Sep;31(9):2018-37.

Vinks TH, Egberts TC, de Lange TM, de Koning FH. Pharmacist-based medication review reduces potential drug-related problems in the elderly: the SMOGcontrolled trial. Drugs Aging. 2009;26(2):123-33.

Volume CI, Farris KB, Kassam R, Cox CE, Cave A. Pharmaceutical care research and education project: patient outcomes. J Am Pharm Assoc (Wash). 2001May-Jun;41(3):411-20.

Westerlund T, Marklund B. Assessment of the clinical and economic outcomes of pharmacy interventions in drug-related problems. J Clin Pharm Ther. 2009Jun;34(3):319-27.

Williams ME, Pulliam CC, Hunter R, Johnson TM, Owens JE, Kincaid J, Porter C, Koch G. The short-term effect of interdisciplinary medication review onfunction and cost in ambulatory elderly people. J Am Geriatr Soc. 2004 Jan;52(1):93-8.

Zermansky AG, Petty DR, Raynor DK, Freemantle N, Vail A, Lowe CJ. Randomised controlled trial of clinical medication review by a pharmacist of elderlypatients receiving repeat prescriptions in general practice. BMJ. 2001 Dec 8;323(7325):1340-3.

Zermansky AG, Alldred DP, Petty DR, Raynor DK, Freemantle N, Eastaugh J, Bowie P. Clinical medication review by a pharmacist of elderly people living incare homes--randomised controlled trial. Age Ageing. 2006 Nov;35(6):586-91.

94


References – Therapy Adherence (1/4)

Balkrishnan R, Kulkarni AS, Cayce K, Feldman SR. Predictors of healthcare outcomes and costs related to medication use in patients with acne in the UnitedStates. Clinical Therapeutics. 2006 Apr;77(4):251-5.

Bolton MB, Tilley BC, Kuder J, Reeves T, Schultz LR. The cost and effectiveness of an education program for adults who have asthma. J Gen Intern Med.1991 Sep-Oct;6(5):401-7.

Bouvy ML, Heerdink ER, Urquhart J, Grobbee DE, Hoes AW, Leufkens HG. Effect of a pharmacist-led intervention on diuretic compliance in heart failurepatients: a randomized controlled study. J Card Fail. 2003 Oct;9(5):404-11. Erratum in: J Card Fail. 2003 Dec;9(6):481

Conn VS, Hafdahl AR, Cooper PS, Ruppar TM, Mehr DR, Russell CL. Interventions to improve medication adherence among older adults: meta-analysis ofadherence outcomes among randomized controlled trials. Gerontologist. 2009 Aug;49(4):447-62. Epub 2009 May 21

Côté I, Grégoire JP, Moisan J, Chabot I, Lacroix G. A pharmacy-based health promotion programme in hypertension: cost-benefit analysis.Pharmacoeconomics. 2003;21(6):415-28

Cramer JA, Benedict A, Muszbek N, Keskinaslan A, Khan ZM. The significance of compliance and persistence in the treatment of diabetes, hypertension anddyslipidaemia: a review. Int J Clin Pract. 2008 Jan;62(1):76-87

DiMatteo MR, Giordani PJ, Lepper HS, Croghan TW. Patient adherence and medical treatment outcomes: a meta-analysis. Med Care. 2002 Sep;40(9):794-811

Ditewig JB, Blok H, Havers J, van Veenendaal H. Effectiveness of self-management interventions on mortality, hospital readmissions, chronic heart failurehospitalization rate and quality of life in patients with chronic heart failure: a systematic review. Patient Educ Couns. 2010 Mar;78(3):297-315

Elliott RA, Barber N, Clifford S, Horne R, Hartley E. The cost effectiveness of a telephone-based pharmacy advisory service to improve adherence to newlyprescribed medicines. Pharm World Sci. 2008 Jan;30(1):17-23.

George J, Elliott RA, Stewart DC. A systematic review of interventions to improve medication taking in elderly patients prescribed multiple medications. DrugsAging. 2008;25(4):307-24

Gibson PG, Powell H, Coughlan J, Wilson AJ, Abramson M, Haywood P, Bauman A, Hensley MJ, Walters EH. Self-management education and regularpractitioner review for adults with asthma. Cochrane Database Syst Rev. 2009

Glynn LG, Murphy AW, Smith SM, Schroeder K, Fahey T. Interventions used to improve control of blood pressure in patients with hypertension. CochraneDatabase Syst Rev. 2010 Mar 17;(3):CD005182;

Greineder DK, Loane KC, Parks P. Reduction in resource utilization by an asthma outreach program. Arch Pediatr Adolesc Med. 1995 Apr;149(4):415-20.

95



Ho PM, Rumsfeld JS, Masoudi FA, McClure DL, Plomondon ME, Steiner JF, Magid DJ. Effect of medication non-adherence on hospitalization and mortalityamong patients with diabetes mellitus. Arch Intern Med. 2006 Sep 25;166(17):1836-41.

Hughes DA, Bagust A, Haycox A, Walley T. The impact of non-compliance on the cost-effectiveness of pharmaceuticals: a review of the literature. HealthEcon. 2001 Oct;10(7):601-15. Review.

Jarab AS, Alqudah SG, Khdour M, Shamssain M, Mukattash TL. Impact of pharmaceutical care on health outcomes in patients with COPD. Int J Clin Pharm.2012 Feb;34(1):53-62. Epub 2011 Nov 20.

Koshman SL, Charrois TL, Simpson SH, McAlister FA, Tsuyuki RT. Pharmacist care of patients with heart failure: a systematic review of randomized trials.Arch Intern Med. 2008 Apr 14;168(7):687-94. Review.

Kotses H, Bernstein IL, Bernstein DI, Reynolds RV, Korbee L, Wigal JK, Ganson E, Stout C, Creer TL. A self-management program for adult asthma. Part I:Development and evaluation. J Allergy Clin Immunol. 1995 Feb;95(2):529-40.

Lau DT, Nau DP. Oral antihyperglycemic medication non-adherence and subsequent hospitalization among individuals with type 2 diabetes. Diabetes Care.2004 Sep;27(9):2149-53.

Lee JK, Grace KA, Taylor AJ. Effect of a pharmacy care program on medication adherence and persistence, blood pressure, and low-density lipoproteincholesterol: a randomized controlled trial. JAMA. 2006 Dec 6;296(21):2563-71.

Lorig KR, Sobel DS, Stewart AL, Brown BW Jr., Bandura A, Ritter P, Gonzalez VM, Laurent DD, Holman HR. Evidence suggesting that a chronic disease self-management program can improve health status while reducing hospitalization: a randomized trial. Med Care. 1999 Jan;37(1):5-14.

Lorig KR, Ritter P, Stewart AL, Sobel DS, Brown BW Jr., Bandura A, Gonzalez VM, Laurent DD, Holman HR. Chronic disease self-management program: 2-year health status and health care utilization outcomes.

Lorig KR, Holman H. Self-management education: history, definition, outcomes, and mechanisms. Ann Behav Med. 2003 Aug;26(1):1-7.

Morris AD, Boyle DI, McMahon AD, Greene SA, MacDonald TM, Newton RW. Adherence to insulin treatment, glycaemic control, and ketoacidosis in insulin-dependent diabetes mellitus. The DARTS/MEMO Collaboration. Diabetes Audit and Research in Tayside Scotland. Medicines Monitoring Unit. Lancet. 1997Nov 22;350(9090):1505-10.

Munroe WP, Kunz K, Dalmady-Israel C, Potter L, Schonfeld WH. Economic evaluation of pharmacist involvement in disease management in a communitypharmacy setting. Clin Ther. 1997 Jan-Feb;19(1):113-23.

96



Murray MD, Young J, Hoke S, Tu W, Weiner M, Morrow D, Stroupe KT, Wu J, Clark D, Smith F, Gradus-Pizlo I, Weinberger M, Brater DC. Pharmacistintervention to improve medication adherence in heart failure: a randomized trial.

Muszbek N, Brixner D, Benedict A, Keskinaslan A, Khan ZM. The economic consequences of noncompliance in cardiovascular disease and relatedconditions: a literature review. Int J Clin Pract. 2008 Feb;62(2):338-51.

Odegard PS, Capoccia K. Medication taking and diabetes: a systematic review of the literature. Diabetes Educ. 2007 Nov-Dec;33(6):1014-29; discussion1030-1. Review.

Osterberg L, Blaschke T. Adherence to medication. N Engl J Med. 2005 Aug 4;353(5):487-97.

Plans-Rubió P. Cost-effectiveness analysis of treatments to reduce cholesterol levels, blood pressure and smoking for the prevention of coronary heartdisease: evaluative study carried out in Spain. Pharmacoeconomics. 1998 May;13(5 Pt 2):623-43.

Renders CM, Valk GD, Griffin S, Wagner EH, Eijk JT, Assendelft WJ. Interventions to improve the management of diabetes mellitus in primary care,outpatient and community settings. Cochrane Database Syst Rev. 2001

Rizzo JA, Simons WR. Variations in compliance among hypertensive patients by drug class: implications for health care costs. Clin Ther. 1997 Nov-Dec;19(6):1446-57;

Roebuck MC, Liberman JN, Gemmill-Toyama M, Brennan TA. Medication adherence leads to lower health care use and costs despite increased drugspending. Health Aff (Millwood). 2011 Jan;30(1):91-9.

Sadik A, Yousif M, McElnay JC. Pharmaceutical care of patients with heart failure. Br J Clin Pharmacol. 2005 Aug;60(2):183-93.

Sokol MC, McGuigan KA, Verbrugge RR, Epstein RS. Impact of medication adherence on hospitalization risk and healthcare cost. Med Care. 2005Jun;43(6):521-30.

Stewart S, Marley JE, Horowitz JD. Effects of a multidisciplinary, home-based intervention on unplanned readmissions and survival among patients withchronic congestive heart failure: a randomised controlled study. Lancet. 1999 Sep 25;354(9184):1077-83.

Taitel MS, Kotses H, Bernstein IL, Bernstein DI, Creer TL. A self-management program for adult asthma. Part II: Cost-benefit analysis. J Allergy Clin Immunol.1995 Mar;95(3):672-6.

Triller DM, Hamilton RA. Effect of pharmaceutical care services on outcomes for home care patients with heart failure. Am J Health Syst Pharm. 2007 Nov1;64(21):2244-9.

97



Tsuyuki RT, Fradette M, Johnson JA, Bungard TJ, Eurich DT, Ashton T, Gordon W, Ikuta R, Kornder J, Mackay E, Manyari D, O'Reilly K, Semchuk W. Amulti-center disease management program for hospitalized patients with heart failure. J Card Fail. 2004 Dec;10(6):473-80.

Van Wijk BL, Klungel OH, Heerdink ER, de Boer A. Effectiveness of interventions by community pharmacists to improve patient adherence to chronicmedication: a systematic review. Ann Pharmacother. 2005 Feb;39(2):319-28.

Weinberger M, Murray MD, Marrero DG, Brewer N, Lykens M, Harris LE, Seshadri R, Caffrey H, Roesner JF, Smith F, Newell AJ, Collins JC, McDonald CJ,Tierney WM. Effectiveness of pharmacist care for patients with reactive airways disease: a randomized controlled trial. JAMA. 2002 Oct 2;288(13):1594-602.

Williams LK, Pladevall M, Xi H, Peterson EL, Joseph C, Lafata JE, Ownby DR, Johnson CC. Relationship between adherence to inhaled corticosteroids andpoor outcomes among adults with asthma. J Allergy Clin Immunol. 2004 Dec;114(6):1288-93.

98


Appendix

99


Overall assumptions

100

Professional Services QuantificationOverall Assumptions

Category Value Source

Population

# of people 65+ 2,567,000 SKF data en feiten (2011)

Polypharmacy patients 65+ 45% van Dijk (2009)

Hospitalizations

Hospitalizations in NL (2008) 1,843,047 CBS Statline 2008

Medication related admission – Average days inhospital 8.70 Beijer (2002), Leendertse (2008)

Cost of hospitalization (incl. complex medical activities) € 3816 CVZ ( €475 per day per hospitalizations)

Cost of hospitalization (excl. complex medicalactivities) € 5461 Leendertse (2010)

Primary Care

Cost of primary care visit € 123 Westerlund (2009)

Medication Cost

Average price of polypharmacy medication € 99 Calculated based on SKF Data en Feiten(2011)


Medication appropriateness is frequently evaluated using the MAIScore – a lower score indicates better medication appropriateness

101

Criterion

Indication Is there an indication for the drug?

Choice Is the medication effective for the condition?

Dosage Is the dosage correct?

Modalities Correct Are there clinically significant drug-diseaseinteractions?

Modalities Practical Are the directions practical?

Drug-DrugInteractions

Are there clinically significant drug-druginteractions?

Duplication Is there unnecessary duplication with otherdrugs?

Duration Is the duration of therapy acceptable?

Costs Is this drug the least expensive alternativecompared with others of equal utility?

MAI Score CriteriaMAI Score

The MAI Score consist of 10 dimensions eachrelating to appropriateness of medication

Every individual patient is reviewed to determinepotential inappropriate prescriptions based on MAIdimensions

The score is computed by awarding eachmedication per patient a score based on the 10MAI dimensions

A weight is applied to each of the dimensionsdepending on the overall objective of the study

The summated MAI Score is calculated for eachpatient by summing the scores of the individualmedication – an average summated MAI Score isthen taken for control and intervention group

The overall change in MAI score can be calculatedbased a comparison of % of patients at baselinevs. follow up

A lower MAI score indicates higherappropriateness of medication, hence a decline inMAI Score can be interpreted as positive

Date post:	24-Apr-2020
Category:	Documents
Upload:	others
View:	6 times
Download:	0 times

KNMP – The potential for pharmaceutical quality services€¦ · KNMP – The potential for...

Documents