Presentation on theme: "Department of General Practice and Primary Care and NHS Grampian"— Presentation transcript:
1Department of General Practice and Primary Care and NHS Grampian Modernising community pharmacy in Scotland- how do we know what the stakeholders want?Christine BondDepartment of General Practice and Primary Care and NHS Grampian
2Acknowledgements Research colleagues Funders Terry Porteous, Mandy Ryan, Tony Scott, Michela TinelliPhil Hannaford, Sally WykeFundersChief Scientist Office, MRC/ESRC, NHS R and D
4Traditional contracts Dispensing of prescriptionsvolume driven paymentDisplaying leafletsProviding opportunistic advice on dispensed medicinesprofessional feeLocally negotiated serviceseg drug misusers, nursing homes, compliance needs assessment, smoking cessationRecognition of other ‘private’ health care rolesSales of OTC medicines
5New UK community pharmacy contracts (Smoking, Health and Social Care (Scotland) Act 2005) Scotland (from July 2006)Four core services provided by all pharmaciesMinor Ailments (MAS)Public Health (PHS)Chronic Medicines Service (CMS)Acute Medicines Service (AMS)Pharmaceutical Care Services PlanLocally negotiated services based on national specificationsPerformers ListSupplementary (and Independent) prescribingOTC sales function still not NHS
10New responsibilities for pharmacy NHS role in self care and provision of advice and supply of medicinesCommunity pharmacy led treatment of minor illnessChronic medicines review and supplyMedication reviewRepeat dispensingPrescribing pharmacistsWhat do pharmacists think?What do patients think?DCEs could have informed both of these
11Will stakeholders accept new policies? Patients DCEs have been used to assessWhat patients value in repeat dispensingBond, C.M. , Matheson C., Jones, J., Williams, S. Repeat prescribing study: an evaluation of the role of community pharmacists in controlling and monitoring repeat prescribing, following protocols agreed with the general practitioner.Report to the Grampian Health Board February 1997Acceptability of prescribing pharmacistTinelli M., Ryan M., Bond C.,Patient preferences for increasing the role of the pharmacist in the management of drug therapy IJPP (R93)Pharmacist role in medication reviewTinelli M., Ryan M., Bond C., Economic evaluation advancement in pharmacy: discrete choice experiments IJPP A12The public’s preferences in self carePorteous, T., Ryan, M., Bond, C., Hannaford, P. Preferences for self-care or consulting a health professional in minor illness; a discrete choice experiment BJGP
12Will stakeholders accept new policies? Pharmacists Pharmacists’ preferences for contractual changesScott. A, Bond, C.M., Inch. J, Grant. A, Preferences of Community Pharmacists for Extended Roles in Primary Care – A Survey and Discrete Choice Experiment. Pharmacoeconomics 2007;25 (9)Pharmacists’ preferences for different attributes of an electronic data interchange systemUbach, C., Bate, A.,Ryan, M., Porteous, T., Bond, C., Robertson, R. Using discrete choice experiments to evaluate alternative electronic prescribing systems.. Int.J.Pharm. Pract 2002; 10:Pharmacists’ decision making in OTC adviceRoins S, Benrimoj SI, Carroll PR et al Pharmacists’recommendation of the active ingredient(s) of non-prescription analgesics for a simple tension and migraine headache JSAP 1998; 15:
13Terry Porteous, Christine Bond, Phil Hannaford, Mandy Ryan, Managing minor illness Factors influencing the choice between self-care and health professional advice: a discrete choice experiment.Terry Porteous, Christine Bond,Phil Hannaford, Mandy Ryan,Sally WykeThis study was part of a research training fellowship funded by the Chief Scientist Office of the Scottish Executive.As we know, self-care encompasses various activities but in this case, I looked specifically at self-care of minor illness rather than self-management of chronic conditions.
14Study designQualitative interviews Aim - To describe what factors influence patients when deciding how to manage minor ailments associated with analgesic useDiscrete choice experiment Aim - To describe what trade-offs people make when deciding how to manage minor ailments associated with analgesic useIt was a two stage process. Qualitative interviews collected in-depth information about how people manage their symptomsAnd the DCE aimed to find the relative importance of the some of the factors that influence people when they decide how to manage symptoms
15Qualitative interviews 24 interviews across Scotland asking about:recent experience and management of symptoms associated with analgesic use.reasons for practising self-care and/or consulting health professionalsopinions on self-care and use of analgesicsInterviewees were a purposive sample of people who had responded to previous survey and had agreed to further participation
16Influencing factors Reasons for practising self-care Faster treatment/easier accessUse of complementary treatmentsAvoidance of unwanted treatmentsFeelings of control/independencePrevious experience of same symptomsAdvice from friends, relatives or mediaPerception that condition is self-inflictedBelief that GP will be of limited helpDoes not want to waste Dr’s timeReasons for not practising self-careHaving to pay for treatments yourselfNo advice from Dr/pharmacistChance of missing important conditionChance of drug interactionsChance of making things worseBelief that nothing can help or stoicismLack of knowledgeBelief that only medical help will workOne of the outputs of this stage was a list of why people do or don’t practise self-care.Some of these are more obvious than others.
17The attributes The “influencing factors” Type of management (self-care, GP, pharmacy, practice nurse, complementary, NHS24, do nothing)Time to treatment (the time you have to wait for an appointment, travel time and time taken to get any treatment) (0,1,5 hours, 1,2,5 days)Cost (travel costs and the cost of any treatment e.g. any consultation fee, over-the-counter medicines, complementary remedies etc.)(£2, £5, £7, £15)The attributes for how people manage symptoms of minor illness were derived from the interview data and these three were chosen because they could potentially be influenced by policy or by varying the model of service delivery.
18The scenario Please imagine this situation: You have a headache and a fever, your bones are aching and your nose feels slightly blocked up. You are still able to do all the things you usually do but are more tired than usual. The symptoms started to appear four days ago, and were slightly worse when you woke up this morning.This scenario was chosen with advice from a GP. It describes a minor condition that in most cases he’d rather not see in his surgery but often does
19A sample question Example Which option would you choose? Option 1 Option 1Option 2Type of managementSelf-careGPAvailability1 hour2 daysCost£2£7We used the attributes to develop a series of choice questions like this one – each of the attributes is included in two service options and respondents had to pick which one they preferred. Each person had to answer 13 of these questions differing in the levels of the attributes.We also collected descriptive data, including demographics, lifestyle data, aspects of health and attitudes to medicines but I won’t be discussing these today..(Tick ONE box only)Option Option Do nothing
20DCE analysis and results DCE administered during November 2005Response rate of 57% (326/573)Analysed using multinomial logistic regressionRegression coefficients used to estimate - utility (“preferences” or “satisfaction”) - willingness-to-payParticipants were selected from the people who responded to our original survey.
21Decreasing preference Overall preferencesFor the symptoms presented:Respondents had a general preference for doing something (rather than “do nothing”)Relative preferences for type of management: Self-care Community pharmacy GP consultation Practice nurse NHS ComplementaryDecreasing preferenceFrom the regression coefficients, we found that respondents had a general preference for doing something rather than doing nothing – so rather than wait and see, they preferred to take actionSelf-care was the most preferred type of management. Advice from a community pharmacy or a GP consultation had similar levels of utility but advice from NHS24 and the complementary option had much less utility.
23Willingness to pay Respondents valued self-care at £ i.e they were prepared to payup to £22.62 to treat thesesymptoms by self-carebut beyond this price,they would rather“do nothing”.
24Willingness to pay They valued other treatment options less highly e.g. they wouldpay £17.01 LESS thanthis to treat symptomsusing the NHS24 option
25Willingness to pay They were prepared to pay £3.69 to reduce the wait to treat symptomsby 1 day
26Moving from one “service” to another Type of managementTelephone advice from NHS24Ask for advice in a pharmacyWait before treating symptoms5 hours1 dayWe can use willingness to pay to compare different configurations of services that might be available
27Moving from one “service” to another Type of managementTelephone advice from NHS24β = -1.48Ask for advice in a pharmacyβ =Wait before treating symptoms5 hoursβ = 5/24*-0.3211 dayβ =Utility of a service = Constant (1.968) +β (service)Moving from NHS24 to pharmacy management gives an increase in “utility” ie β (NHS24) – β (pharmacy) = – (-0.304)=We can use willingness to pay to compare different configurations of services that might be available
28Moving from one “service” to another Type of managementTelephone advice from NHS24Ask for advice in a pharmacyWait before treating symptoms5 hoursβ = 5/24*-0.3211 dayβ =Utility of a service = Constant (1.968) +β (service)Moving from a wait of 5 hours to 1 day gives a decrease in “utility”ie β (5 hours) – β (1 day) = – (-0.321)=We can use willingness to pay to compare different configurations of services that might be available
29Moving from one “service” to another Type of managementTelephone advice from NHS24Ask for advice in a pharmacyWait before treating symptoms5 hours1 dayOverall difference in “utility” is positive and we can quantify it by WTPU (service 1) – U (service 2)/ β (cost) = /-0.087= £10.60Rather than get telephone advice from NHS24 with a 5 hour wait, a respondent would be willing to pay an extra £10.60 to get advice from a pharmacy with a wait of 1 dayWe can use willingness to pay to compare different configurations of services that might be available
30ConclusionsSelf-care was the preferred way of dealing with these symptomsIt was highly valued by respondentsCommunity pharmacy was the preferred source of professional adviceDCE allowed quantification of preferences and expressed them by WTP
31Assessing what patients liked about pharmacist led medicine management Tinelli M, Ryan M, Bond C
32The Community Pharmacy Medicines Management Project* Aim: to evaluate the introduction of the Medicines Management Service by community pharmacists for patients with CHDRandomised Controlled TrialSetting: Nine Health Authorities in England, 50 Community pharmacies, 39 General PracticesPrimary subjects: Patients with CHDIntervention: Community Pharmacy face-to-face patient review to include medication and lifestyle adviceControl: Usual careThe Community Pharmacy medicines Management Project Evaluation team (C. Bond Principal Investigator) The MEDMAN study: a randomized controlled trial of community pharmacy-led medicines management for patients with coronary heart disease. Family Practice 2007; 24(2):
33The Community Pharmacy Medicines Management Project Primary outcome measures: appropriate treatment (derived from the NSF), health status (EQ5D and SF36)Secondary outcome measures: satisfaction, experiences and attitudes of patients and health care professionalsTime period: All measures were assessed at baseline and 12 monthsResults: no changes in clinical or QALY outcomes; patients satisfaction higher in the intervention groupTo use a DCE toExplain the increased satisfactionInform a CBA for the community pharmacy-led medicines management service
34Use of DCE Identification of attributes from replies to patient survey DCE survey questionnaires sent to all patients participating to the trial 2 years after study start (879 intervention; 470 control)DCE compared three options:a novel community pharmacist and general practitioner review of medicines (CPGP)a GP only medicines review (GP)the current scenarioWTP in moving from the current situation to ‘CPGP’ or ‘GP’ were estimatedGroups compared:intervention all vs control (TAU) (ITTA)intervention still receiving the Medman service vs control (TAU) (PPA)A priori assumed people who had experienced the service more likely to value it
35Attributes Advice Time (travelling to and in the pharmacy) None, only on medicines, only on health/lifestyle, bothTime (travelling to and in the pharmacy)10,20,30,40 minPrivacy (in the pharmacy)Satisfactory replies to questionsYes, NoChance of receiving most appropriate treatmentVery poor, poor, good, very goodHow much you pay ( medicine + advice+ review+ travel)£0, £10, £20, £30
36Example of DCE choice Medicines review by GP and Pharmacist Medicines review by GP onlyCurrent situationADVICEOn medicine & health/lifestyleNoPRIVATE DISCUSSIONYesSATISFACTORY REPLIESCHANCE OF APPROPRIATE TREATMENTVery goodTIME (Travelling to + waiting in the pharmacy)10 minutesHOW MUCH YOU HAVE TO PAY (Consultation + medicines + travelling)£ 10WHICH SERVICE WOULD YOU CHOOSE? (Tick one box only)
37Results Response rates: Intervention (73%) and Control (67%) 44% of intervention still receiving the service, 52% stopped , 4% neverThe preferred option for all groups was the current optionControls:‘Chance of receiving the best medicine’ and ‘cost’ were most importantIf moving from the current service would choose the GP only option
38Intervention groups Intervention all ‘Advice on medicines’, ‘satisfactory replies’ as well as ‘chance of receiving the best medicine’ and ‘cost’ were most importantIf moving from the current service would choose the GP only optionIntervention still receiving the service‘Advice on medicines’, ‘satisfactory replies’, ‘chance of receiving the best medicine’ and ‘cost’ remained most important plus ‘advice on medicines and lifestyle’If moving from the current service would choose the combined GP-pharmacist option
39Willingness to pay Intervention all Valued their current service at £19.28Intervention still receiving the serviceValued their current service at £21.99Would pay £50 to move to a GP-pharmacist serviceControl groupsWould pay £17.09 to stay with their current service rather than move to GP-pharmacist service
40Cost benefit analysis for trial ControlIntervention allIntervention still receiving the serviceMean extra benefits per patient (from DCE)-£17.09£19.28£21.99Mean extra cost per patient£32.67£18.16Mean net benefits per patient£-49.76£1.12£3.83
41Decision making process Efficient allocation of resources Outcome measuresResultsEconomic evaluationClinical outcome(Appropriateness of treatment)NO difference across groupsCost minimisationResults: increased total NHS costs with the introduction of the serviceQALY (EQ5D and SF6D)DCEsDifferences across groups: Subjects who experienced the new service valued the input from their pharmacists, and preferred it to any other optionCost benefit analysisResults: The increase in intervention costs was partially compensated by increased patients’ valuation for that service
42ConclusionPatients value the opportunity to have input from both pharmacist and GPExtra costs of delivering the pharmacy led medicines management service were partially offset by increased value to patientsThe DCE methodology:helped understand what patients valuedquantified value of the service within a CBAis useful for use in pharmacy policy decision making
43SummaryDCEs can inform emerging policy and evaluate implemented policyAdd a dimension not otherwise availableIn pharmacy research has explained what stakeholders want and how it is valued