Better than an iPad app … a

clinical pharmacist in your

practice team.

Dr Peter Culham

Vanessa Brown

Brendan Duck

RNZCGP GPCME 2014

Can you answer these questions?What is the latest regarding metformin use and eGFR?

When might you use bisoprolol?

When should you use aspirin and warfarin?

Have you audited your...

– Amiodarone patient monitoring

– Methotrexate monitoring

– Citalopram and QT prolongating medicines

!You need a Clinical Pharmacist!

Mr J.R.75 year old male

IHD, MI 1996, MI 2003, multi-vessel disease stented

CHF, severe on basis IHD, echo 2004 EF 21%

Permanent AF on warfarin

GI bleed, duodenitis from

NSAIDs 2009, further 2011

Gout, polyarticular,

tophaceous

Mr J.R.

Warfarin 5mgDigoxin 125mcgOmeprazole 40mgSpironolactone 25mgAtorvastatin 20mgDiltiazem CD 180mgFurosemide 160mgLosartan 50mgSeretide 50mcg BDAllopurinol 200mg (since 2005)

Mr J.R.

June 2011, rash on legs, lifelong eczema but not responding to Locoid

August 2011, intolerable pruritus, excoriated rash over entire body

October 2011, punch biopsy spongioticdermatitis, allopurinol stopped by GPSI. Reducing prednisone 20mg to 5mg

April 2012, severe gout, prescribed colchicine

May 2012, gout left knee, confirmed on aspiration, prescribed colchicine

Mr J.R.

Remains on 2-3mg prednisone, declines allopurinol, urate 0.75mmol/L

Increased tophaceous changes in hands

Frequent use of colchicine for gout attacks

Declines Specialist review

What do you do?

Mr J.E

MIMS Interactions example

What is a Clinical Pharmacist?

Specialist Pharmacist Practitioner

Post-Graduate education and/or significant clinical experience

Undertakes Medicine Reviews = Medicine Therapy Assessment (MTA)

Provides medicine and clinical information services

What's different about a Clinical Pharmacist?

Focus on risk vs benefits for individual patients for each medicine

Applying most recent evidence to specific patient medicine related problems

Recommendations on how to implement treatment plan

Unbiased assessment of emerging medicine evidence and guideline updates

Mrs F.J.

76 year old female

Her current issues include:

Tiredness, cramps and twitchy legs

Constipation, renal function changes

Falling regularly

BP 120/58mmHg Calc CrCl = 21.5mL/min

HbA1c 37mmol/mol Cholesterol levels good

Liver function good

Current meds

Furosemide 80mg mane

Amitrip 25mg nocte

Ezetrol 10mg daily

Aspirin 100mg daily

Quinine 300mg BD

Simvastatin 40mg nocte

Omeprazole 20mg mane

Cholecalciferol 1.25mg monthly

Recommendations

Change simvastatin 40mg to atorvastatin 10mg

Stop omeprazole

Stop quinine

Follow-up

Feeling much better

No longer tired

Birth of clinical pharmacist facilitation?

$1.06 million year on year increase in combined pharmaceutical budget– CPB = community pharmaceuticals

+ pharmaceutical cancer treatments

+ vaccines (from 1 July 2013)

Not sustainable

No ‘low hanging fruit’

Demographics (2013 census)(1)

Population 152,000NZ population 3.4%Māori 23.1%

(NZ 15.4%)

Pacific 4.1%

65-84 years 14.8%

(NZ 11.9%)

85 years 2.1%

(NZ 1.6%)

Aging PopulationItems Dispensed per Capita by Age

Source: Pharmaceutical Claims Data Mart, Ministry of Health (Extracted: 22/4/2011). Note data subject to

change over time.

Under-utilisation

Unmet need

– Access

Disparity in Māori/Pacific Island

– Under-utilisation of medicine

– Higher levels of disease with poorer outcomes

Legend

At goal <53

53 - 64

Not at goal >64

Diabetes Patients HbA1c - 2010

How would

you address

these

problems?

Dr Info

The model

Clinical pharmacist facilitators (1.5 FTE)

Focus on best practice – not cost

To complement the population based clinical pharmacist facilitator (1.0 FTE)

Proof-of-concept

Funded by Hawke’s Bay DHB– working out of Health Hawke’s Bay PHO

– in specific practices (0.5 FTE x 3)

Aims

Interventions targeted at polypharmacy

– ≥ 65 years

– Would not disadvantage Māori, Pacific or NZDep 9/10

Polypharmacy

– patient harm / ADRs

Improve chronic disease

outcomes (CV risk, diabetes)Fulton & Allen 2005

Practice Focuses

Patients >65 years residing in Age Related Residential Care (ARRC) facilities

Patients who are over 65 years living independently in the community

Practice - with high needs population (Māori, Pacific or NZDep 9/10)

The Practices

TE MATA PEAK PRACTICE

GREENDALE FAMILY HEALTH CENTRE

TOTARA HEALTH

Location Havelock North Taradale Hastings & Flaxmere

Targeted population

Patients 65 years and over, living in Age Related Residential Care Facility

Patients, 65 years and over, living independently in the community

Patients with high needs including Māori, Pacific and NZDep 9/10

Enrolled Population 9800 6000 11000

Target Population 175+ 1200 7029

Evolution of role

Relationship building

Initial focus was on patients taking >10 meds

Medicines rather than people

Development of tools to generate referrals

Quality activities

Demand for services

GP Quote

“Initially I had no idea what a Clinical Pharmacist would do for our practice, now I don’t know how I could live without them.”

Totara Health

Individual vs Population Focus– Individual reviews = large benefit for

individuals ≠ large benefit for high needs population

– Focus on population with chronic disease with poor outcomes

– Targeted review of medicines treating chronic disease and recommendations to GP

Diabetes Patients BP Comparison 2010 to 2013

Adherence

Number of risk factors for non-adherence per patient

032%

137%

222%

3 or more9%

Mr T.J.

Male, 63 year old, Cook Island Māori

Labels

– ‘Non-compliant’

– ‘Poor diabetes control due to religious beliefs’

Problem

– Poor understanding of his medicines

– Strong beliefs in value of nutrition and ‘living off the land’

Mr T.J.

Type 2 Diabetes

Recent admission for Heart Failure

Recent admission for cellulitis

Cancellation of cataract surgery

– Poorly controlled hypertension and diabetes

HbA1c 123mmol/mol

BP 195/110mmHg

LDL 4.5mmol/L

Mr T.J.

Intervention

– Improve understanding of medicines

– Sustained adherence to medicines (BP, lipid and diabetes)

BP 120/70mmHg

HbA1c 56mmol/mol

LDL 2.5 mmol/L

No recent HF symptoms

– Teaching others about the benefits of medicines

Te Mata Peak Practice

Primarily Aged Related Residential Care

Aims:

– Reduction in polypharmacy

– Improve medicine safety

Medicine reconciliation on admission

Medicine Therapy Assessment prior to 3/12 review

Medicine related quality initiatives

Digoxin administration and monitoring

Medicines and Falls Risk

Mr A.H.

Male, 76 year old

PAF, heart failure, asthma, osteoarthritis, IHD

3/12 review with locum

Dizzy and unwell

Feeling tired and unable to eat – 10kg weight loss over 2 months

BP 79/50 mmHg

Mr A.H.

Medicines– Dabigatran 110mg bd– Furosemide 120mg mane– Terazosin 15mg mane– Candesartan 32mg mane– Diltiazem 240mg mane– Tramadol SR 100mg bid– Prednisone 10mg mane– Fosamax Plus® weekly– Calcium 500mg daily– Symbicort 200/6 2puffs bd– Budesonide NS 100mcg bd– Salbutamol 200mcg prn

Mr A.H.

Changes– Reduced furosemide to 40mg over time

– Terazosin reduced and switched to tamsulosin

– Candesartan reduced

– Diltiazem reduced

– Dabigatran stopped – GI ADR’s

– Trial discontinuation of tramadol – restarted

– Regular paracetamol started

Results– Feeling better, reduced dizziness, better appetite

Greendale Family Health

Focused on ≥ 65 years living at home

Medicine therapy assessments

Co-ordination of multiple prescribers!

Medicine reconciliation

Clinical guidelines and standing orders

Linkages

Health Hawke’s Bay PHO

Care cluster

Home services

District nurses

Local specialists

Hospital pharmacists

Community pharmacist

Allied health: OT, PT, dietitian, social worker

Tools used – Multi-Med Survey

Tools Used – S.I.M.P.L.E.

Medicine reconciliation

Update medical record 37%

Required clarification 29%

Required a medicine review

as multiple issues 23%

Other interventions 11%

E.g. Advice on syringe driver medicine doses

Medicine information queries

Special authority number follow-upGreendale: 1 December 2012 – 18 January 2013

Prescribing cascade

Mr L - 92 year old: Type 2 Diabetes, Hypertension, Angina, Hypercholesterolaemia

Bladder tumor 2000 + 2003 with urgency issues

Patient’s issues

Dry mouth, foggy head, tired all the time

Constipation, nausea, off balance

Medicines and clinical readings

Metoprolol CR 47.5mg

Felodipine ER 10mg

Aspirin EC 100mg

Cilazapril 1mg

Bendrofluazide 2.5mg

Metformin 1g mane, 1.5g nocte

Vesicare 5mg nocte

Lactulose 30-50ml daily

Laxsol 1-2 nocte

BP 120/70mmHg

No recent HR recorded

HbA1c 46mmol/mol

eGFR 32 mL/min

Na+ 128 mmol/L

No LFTs since 2005

Pharmacist recommendations

Stop Vesicare: ADR outweigh benefit in this patient

Decrease metformin to 500mg BD in view of eGFR and HbA1c

Stop bendrofluazide due to low Na+, eGFR and low BP

3/12 renal function + electrolytes, BP + HbA1c

Annual liver function

Patient follow-up

Follow-up 2 weeks laterPatient feels so much better, no longer needing day time sleepsEating better due to no nausea and mouth less dryHead much clearerBowels opening daily with easeBalance greatly improved

3/12 laterBP 128/70mmHg (120/70)HbA1c 53mmol/mol (46)eGFR 30mL/min (30)Na+ 136mmol/L (128)QoL improvement ++

Benefits to General PractitionerHigh quality unbiased advice

Different set of eyes/focus

Collaborative decision making

Source of information on constantly changing evidence and guidelines

Availability of medicine information

Coordination of multiple prescribers

MOPS audits

Benefits to Practice

Collaboration to manage chronic disease

Increased practice confidence in managing polypharmacy

Contribution to quality improvement of the practice

Review of medicine policies and standing orders

Cornerstone accreditation support

RN quotes – how has the Clinical Pharmacist helped?

“Resource for education of nurses, patients, GPs. Can't imagine not having CP here now as I probably access CP expertise daily…”. Practice Nurse

“Education. Medication Reviews. Input into best practice projects. Liaison between GP and facility when required”. Registered Nurse – ARRC

Benefits to patients

Different focus, asks different questions

Address medicine benefits vs harm

Improved outcomes

Reduced medicine complexity

Coordination of multiple prescribers

Mr H.W.

83 year old

18 months ago admission to HB Hospital CCU with ACS, transferred to Wellington cardiology for stent

Medicines charted incorrectly at Hawke’s Bay Hospital, copied in Wellington, patient discharged home on incorrect medicines

Recognised and stopped, following review by pharmacist

Cost reduction / avoidance

Category Cost $p.a. or per event*

Number of eventsKnown / estimated*

Total DHB savingsKnown / estimated*

1. Community

pharmaceuticals

¥$500,000

2. Falls $0 to $47,000 64 $149,400

3. Reduction in BP § *3 *$100,000

4. Delayed admission to

ARRC$24,000 2 $48,000

5. ED transfer avoided $450 *1 *$450

Total ~$800,000

¥ Hawke’s Bay CPB September 2012 to August 2013§ Reduction in sBP by 10mmHg (1 each renal failure, myocardial infarction, stroke)

Hawkes Bay Future Direction

Clinical Pharmacist Facilitators add value to general practice

1 FTE per 20,000 patients

Ensure access to all areas within DHB

As 1 July 2014, Hawke’s Bay DHB is rolling out this service Hawke’s Bay wide (8 FTE)

We Can Help You

Evidence to support clinical pharmacist role

Experience of implementation

Contact:

– Billy Allan, Chief Pharmacist, HBDHB

William.Allan@hawkesbaydhb.govt.nz

– Di Vicary, Health Hawke’s Bay

pharmacist@healthhb.co.nz

Acknowledgments

Di Vicary, Clinical Pharmacist Facilitator Team Leader

Billy Allan, Chief Pharmacist

Hawke’s Bay DHB

Health Hawke’s Bay

Greendale Family Health

Te Mata Peak Practice

Totara Health

Any Questions?

GP Quote“A couple of years down the track I now have had the benefits of working with 2 amazing people as pharmacy facilitators, and never cease to be amazed at their depth of knowledge and willingness to research any pharmaceutical topic which presents a problem to my colleagues or myself. They have then presented the information in clear and practical fashion making it unnecessary for me to struggle with the long and complicated presentations of scientific papers. In addition their help with sorting potential problems which crop up from time to time in the media has been amazing, finding which patients are potentially affected, and then advising on the best way forward based on the best evidence.”