1. pharmaSuisse Models for Evidence-based Therapeutic Decision- making and Therapeutic Management Martine Ruggli Pharmacist FPH pharmaSuisse Switzerland

2. pharmaSuisse 1. Prescription data (benchmarking per physician and therapeutic class) 2. Education on guidelines, Evidence-based medecine and pharmacoeconomy. 3. Analysis of prescription attitudes in comparison with scientific and economic data and search for alternatives in drug market 4. Consensus of each quality circle 5. Application of the consensus 6. Check on the impact of the consensus 7. Assessment of the results and improvements Work process Continous quality improvement of prescription Resume of the expose 2 models : 1.Collaboration with physicians to improve prescription practice 3 applications implemented in Switzerland : o Quality circles physicians-pharmacists o Pharmacist consulting in nursing homes o Expertise of prescription profile of the physician. 2.Integrated Networks Pilot project in e-health

3. pharmaSuisse 1. Prescription data (benchmarking per physician and therapeutic class) 2. Education on guidelines, Evidence-based medecine and pharmacoeconomy. 3. Analysis of prescription attitudes in comparison with scientific and economic data and search for alternatives in drug market 4. Consensus of each quality circle 5. Application of the consensus 6. Check on the impact of the consensus 7. Assessment of the results and improvements Work process Continous quality improvement of prescription Level of collaboration between pharmacists and other healthcare professionals Quality circles Nursing home consulting

4. pharmaSuisse 7.Assessment of the results and improvements 1. Prescription data 2. Guidelines and Evidence-based medecine 3. Analysis of prescription attitudes in comparison with scientific and economic data and search for alternatives in drug market 4. Consensus 5. Application of the consensus 6. Check on the impact of the consensus 1. Prescription data (benchmarking per physician and therapeutic class) 2. Education on guidelines, Evidence-based medecine and pharmacoeconomy. 3. Analysis of prescription attitudes in comparison with scientific and economic data and search for alternatives in drug market 4. Consensus of each quality circle 5. Application of the consensus 6. Check on the impact of the consensus 7. Assessment of the results and improvements Work process Continous quality improvement of prescription First model: collaboration with the physician to improve prescription practice

5. pharmaSuisse Physicians-Pharmacists Quality Circle

6. pharmaSuisse 1. Prescription data (benchmarking per physician and therapeutic class) 2. Education on guidelines, Evidence-based medecine and pharmacoeconomy. 3. Analysis of prescription attitudes in comparison with scientific and economic data and search for alternatives in drug market 4. Consensus of each quality circle 5. Application of the consensus 6. Check on the impact of the consensus 7. Assessment of the results and improvements Work process Continous quality improvement of prescription What is a Physicians-Pharmacists Quality Circle ? A stable group of 5-15 GPs and 1-2 pharmacists as moderators Meeting voluntarily Evaluation of the daily prescribing practice Working together to continuously improve their practice This means that every participant is active!

7. pharmaSuisse 7.Assessment of the results and improvements 1. Prescription data (benchmarking per physician and therapeutic class) 2. Guidelines and Evidence-based medecine 3. Analysis of prescription attitudes in comparison with scientific and economic data and search for alternatives in drug market 4. Consensus of each quality circle 5. Application of the consensus 6. Check on the impact of the consensus 1. Prescription data (benchmarking per physician and therapeutic class) 2. Education on guidelines, Evidence-based medecine and pharmacoeconomy. 3. Analysis of prescription attitudes in comparison with scientific and economic data and search for alternatives in drug market 4. Consensus of each quality circle 5. Application of the consensus 6. Check on the impact of the consensus 7. Assessment of the results and improvements Work process Continous quality improvement of prescription Application of the model in physicians - pharmacists quality circles:

8.  Cercles de qualité pharmaSuisse Saving in 2009  170’000 € per physician M. Ruggli, O.Bugnon / 2009 Source de données brutes : OFAC (2009) Economic impact on drug cost: 11 years experience in Fribourg +1.7% +3.7%

9. pharmaSuisse More balanced attitude towards marketing strategies: example of aliskiren Better awarness of the risk of drugs: example of rimonabant Better use of the suitable drug: example of fluoroquinolone "Circle effect": more than just cost saving

10. A real collaborative practice and not a dream! The objectives: –optimize the safety and effectiveness of the treatments for the patients. –more efficient spreading of the pharmacovigilance messages –saving capacity on medicine costs based on professional decisions and not on price reductions. –increased resistance of the Healthcare professionals against industrial marketing activities. –recognized interdisciplinary education in favor of person- centered care. BUT it is absolutely necessary to be persistant to get results Quality circles after 11 years…which is the constancy?

11. Quality circles implemented in nursing homes: pharmacist consulting

12. -42 nursing homes -2'214 patients -22 pharmacists -Growth of the drugs cost -Modification of the Fribourg cantonal health legislation Dissemination and implementation of the service Development of pharmaceutical care services and research in a Swiss canton, Pharm World Sci, 2008

13. 7.Assessment of the results and improvements 1. Prescription data Statistics of drug consumption in the nursing home 2. Guidelines and Evidence-based medecine 3. Report of the pharmacist: analysis of prescription and search for alternatives 4. Discussion of the report with all health care professionals of the nursing home and agreement on a consensus 5. Application of the consensus 6. Check on the impact of the consensus 1. Prescription data (benchmarking per physician and therapeutic class) 2. Education on guidelines, Evidence-based medecine and pharmacoeconomy. 3. Analysis of prescription attitudes in comparison with scientific and economic data and search for alternatives in drug market 4. Consensus of each quality circle 5. Application of the consensus 6. Check on the impact of the consensus 7. Assessment of the results and improvements Work process Continous quality improvement of prescription Application of the model in nursing home

14. Evaluation of the economic impact of this service in nursing homes Medications: «Implemented since 2002, pharmaceutical care services have allowed to decrease the costs in a dramatic way »

15. Evidence-based practice recommendations in psychogeriatrics for Elderly Pharmacological management of 1) cognitive symptoms of dementia and delirium; 2) behavioral and psychological symptoms of dementia (depression, sleep disturbances, agitation) 1.Need identification 2. Interdisciplinary working group 3. Systematic literature Review 4. Treatment algorithms 5. Dissemination, education 6. Evaluation

16. Publications

17. expertise of the prescription profile of the physician

18. 1. Prescription data (detailed analysis to define the prescription profile) 2. Guidelines and Evidence-based medecine 3. Analysis of prescription attitudes in comparison with scientific and economic data 4. Highlight of the possible savings 5. Modification of the prescription if necessary 6. Check on the impact 1. Prescription data (benchmarking per physician and therapeutic class) 2. Education on guidelines, Evidence-based medecine and pharmacoeconomy. 3. Analysis of prescription attitudes in comparison with scientific and economic data and search for alternatives in drug market 4. Consensus of each quality circle 5. Application of the consensus 6. Check on the impact of the consensus 7. Assessment of the results and improvements Work process Continous quality improvement of prescription Application of the model in the expertise of the prescription profile of the physician

19. pharmaSuisse Annual survey from the health insurance to determinate the cost of the drugs prescribed by physicians during one year. If too high (30% more than the mean value) the physician gets a warning and has to justify his costs Other use of the prescription data of the physician

20. pharmaSuisse Analysis of the drug costs How can the pharmacist help ? Therapeutic classes Cost in 2007Cost in 2008 Antihypertensive drugs65395.0569392.25 Hypercholesterolemia treatment28753.5532530.9 Proton pump inhibitors66699.958004.85 NSAID43014.142778.9 Antiasthmatic drugs37435.8531818.25 Antidepressant drugs26372.828434.95 Antidiabetics32007.1532579.65 Antibiotics33213.6537294 Analgesics44306.687606.7 Neuroleptics49958.4552487 Anticoagulants11748.9510928.05 Calcium channel blocker12943.511836.6 Tranquilizers21261.3521164.75 Beta blockers6095.356363.3 Hypnotics21979.5518386.4 Diuretics9066.159743.2 Vasodilatators7814.358075.05 Antacids3838.652664.7

21. pharmaSuisse Cost = price * volume * frequency of prescription Parameters needed to understand where is the problem: cost per patient price per unit number of units par patient frequency of prescription How can the pharmacist help ?

22. pharmaSuisse PhysicianCost/patientPrice/unitUnit/patient Prescription frequency (%) Dr Friend937013442.2 Dr Collegue564014117 Dr Long513215932 Dr Friend Cost evolution of analgesics 20072008Difference 31000€62575€31575€ Dr Michel Buchmann, 08.2009 Fine analysis of the prescription of analgesics 2008

23. pharmaSuisse Dr Michel Buchmann, 08.2009 Fine analysis of the prescription of analgesics hydromorphoneAcetaminophenFentanylOxycodon Tramadol + acetaminphen

24. pharmaSuisse Dr Michel Buchmann, 08.2009 Hydromorphone: just for 1 patient This patient can’t take any other painkiller, using high dose of hydromorphone to be able to control his pain Cost of 22’223 € in 2008 that the physician can’t be made responsible for Other saving possible through generics substitution of all fentanyl originals: 2857 € Fine analysis of the prescription of analgesics

25. pharmaSuisse Dr Michel Buchmann, 08.2009 Same analysis for all the therapeutic classes Switch to generics But especially therapeutics switches towards better evaluated and less expensive drugs Example: ezetimibe => potent statin = saving of 1428 € per year nevibolol => bisoprolol or metoprolol = saving of 285 € BUT ALWAYS KEEP IN MIND THAT QUALITY IS THE CENTRAL POINT Next step: fine analysis of the prescription of all therapeutic classes

26. pharmaSuisse Based on the data of the quality circle, we showed that Dr Friend could reduce the drug costs but only in a small way (3 %). This demonstrates that these 10 years working in quality circle carried their fruits: Dr Friend is a physician aware of the drug costs, prescribing the best evaluated drugs, with the best economical potential; the extra costs are due to specific situations, not influenced by the prescriber Dr Friend absolutely satisfies the criteria of the health insurance. Dr Michel Buchmann, 08.2009 Analysis summary Letter for the Health Insurance:

27. pharmaSuisse To implement projects: what is important? Get recognised Get paid These services are new services that have to be remunerated separately.. Impossible with a margin system …. => Change the remuneration system and pay for services = THAT‘s the KEY All the projects are realised in ambulatory sector Keep im mind that politicians want to slow the costs’ growth

28. pharmaSuisse Where do we go?

29. pharmaSuisse 27/10/15 29 Integrated care « specialized » pharmaceutical services « basic » pharmaceutical services Consulting in nursing homes Quality circles physicians - pharmacists New direction: integrated care Pharmacist Patient Pharmacist Physician Patient

30. pharmaSuisse Pilot project: collaboration with telemedicine

31. pharmaSuisse Pharmacist specially trained to work with algorithms for different diseases Pilot project: collaboration with telemedicine If the patient needs a consultation, he is given the choice of visiting his physician if he has one or getting the service of a physician from Medgate, the biggest center for telemedicine of Switzerland

32. pharmaSuisse This contact with Medgate is realised via videoconsultation which enables the physician to see the patient Pilot project: collaboration with telemedicine physicians Discussion between physician, patient and pharmacist about the case and the treatment. If necessary, the treatment will be prescribed by the physician and delivered by the pharmacist directly If the case requires a bigger intervention, the patient will be oriented to a physician or an hospital

33. pharmaSuisse Future of the profession of pharmacists: Think services Think remuneration system partially based on fee for services Organise education Add motivation and enthusiasm! Conclusion

34. pharmaSuisse Thanks to Michel Buchmann Dominique Jordan and pharmaSuisse Olivier Bugnon and Jean-François Locca, University of Geneva

35. pharmaSuisse Thanks for your attention