HMRs In Australia: It can be a family affair Mark Naunton BPharm (Hons), MPS, MSHPA, PhD, AACPA (Acting) Head of Pharmacy May 29 th 2013 CRICOS #00212K Overview Duration of service delivery Process and Payments Statistics and Hurdles Recent Developments in Australia Medication Review Training @UC Cases from a Dutch HMR accredited pharmacist Odds and Ends (if time) Presentatie van Mark Naunton BPharm (Hons), MPS, MSHPA, PhD, AACPA 1
Overview Australian Population Pharmacies Pharmacists Accredited Pharmacists Process and Payment 1 2 3 4 6 7 8 Identify the patient for HMR (any member of the healthcare team, patient or carer) GP initiates and refers to community pharmacy OR Pharmacist (2012) Pharmacist conducts patient interview (accredited or community pharmacist) Pharmacist prepares Medication Management Review (accredited pharmacist) Pharmacist sends report to GP ($200.00) GP consultative management plan for patient GP sends management plan to pharmacy/pharmacist ($150.00) Presentatie van Mark Naunton BPharm (Hons), MPS, MSHPA, PhD, AACPA 2
HMR Statistics (2001-2013) ~150,000 Presentatie van Mark Naunton BPharm (Hons), MPS, MSHPA, PhD, AACPA 3
HMR Statistics (2001-2010) Other Paid Programmes MedsCheck (MUR) n~13000 Oct-Dec 2012 Diabetes Check n~3000 Oct-Dec 2012 Clinical Interventions RMMR QUM Presentatie van Mark Naunton BPharm (Hons), MPS, MSHPA, PhD, AACPA 4
UC Training for Medication Review UC Training for Medication Review MedicineSmart@UC 2 contracts Presentatie van Mark Naunton BPharm (Hons), MPS, MSHPA, PhD, AACPA 5
UC Training for Medication Review Hospitalised for heart failure in 2011 verapamil, monopril, hydrochlorothiazide frusemide Sitaglitpin, gliclazide, Insulin glargine (Lantus) BSLs 10-14 (HbA1c 11.2%) Outcomes. UC Training for Medication Review Presentatie van Mark Naunton BPharm (Hons), MPS, MSHPA, PhD, AACPA 6
UC Training for Medication Review Meet Katja MPharm (RuG) Veendam Aust: 2006 HMR 2009 ~1000 Locum PhC Presentatie van Mark Naunton BPharm (Hons), MPS, MSHPA, PhD, AACPA 7
Referral Case 1 77 yrs Urgent HMR Nausea, weight loss (suspect ADR) 7/2/13 Dementia Severe depression OSA Valvular Heart Disease Mild aortic stenosis Chol Hypertension Meniere s disease OA T2DM (Feb 2012) Tiredness (Dec 2012) Orthostatic hypotension (21/1/13) Prescribed Drug and Dose Gliclazide MR 60mg: 1 tablet daily Domperidone 10mg: 1 tablet tds prn Fentanyl 100 Patch: 1 every 3 days Frequency according Purpose to patient according to pt 1 tablet daily (packed in? Medico pack) 1 tablet three times a day Dizziness, nausea 1 patch every 4 days Pain Reboxetine 4mg: 1 ½ tablet daily 1 ½ tablets daily (packed in Medico pack) Ferrous fumarate/folic acid 1 tablet daily (packed in 310mg/350mcg: 1 tablet daily Medico pack) Sitagliptin/Metformin 1 tablet twice daily 50/1000mg: 1 tablet twice daily [ (packed in Medico pack) Atorvastatin 10mg: 1 tablet daily 1 tablet daily (packed in [Lipitor ] Medico pack) Prazosin 1mg: ½ a tablet twice a ½ a tablet twice daily day (packed in Medico pack) Mirtazapine 45mg: 1 tablet at 1 tablet daily (packed in night Medico pack) Paracetamol 500mg: 2 tablets Not using qds prn Moxonidine 400mcg: 1 tablet Stopped by cardiologist daily Betahistine 16mg: 1 tablet twice 1 tablet twice daily daily (packed in Medico pack) Ramipril 2.5mg: 1 capsule daily 1 tablet daily (packed in Medico pack) Prescribed Drug and Dose Frequency according to patient Depression???? Depression?? Purpose according to pt Diltiazem 60mg 2 tablets in the morning and Palpitations 1 tablet at night Glucosamine 750mg 1 tablet daily Arthritis Presentatie van Mark Naunton BPharm (Hons), MPS, MSHPA, PhD, AACPA 8
Case 1 Case 1 Presentatie van Mark Naunton BPharm (Hons), MPS, MSHPA, PhD, AACPA 9
Case 1 NB: no anticoagulant, Fe supps, no pain, Betahistine ineffective, Case 2 76 yrs > 5 meds Pt. request 27/2/13 Patient concerns Nausea, constipation Sertraline not effective Suspected UTI? Hexamine recently ceased Abx not working. Presentatie van Mark Naunton BPharm (Hons), MPS, MSHPA, PhD, AACPA 10
Case 2 Hypertension Mild COPD/Asthma Diverticular disease Spondylosis # NOF (OP) CKD (stage 3) Recurrent UTI Dyslipidaemia Insomnia Dry eyes Bilateral cataracts etc. Prescribed Drug and Dose Frequency according to patient Purpose according to pt Aspirin 100mg: 1 tablet daily 1 tablet daily Prevent stroke Candesartan/Hydrochlorothiazide 16/12.5mg: 1 tablet daily ½ a tablet daily Blood Pressure Calcium 600mg & vitamin D 400IU: 1 tablet twice daily Supplement 1 tablet bd Fish oil 1000mg 1 capsule daily Glucosamine 1000mg Is using 1 tablet that contains glucosamine 1500mg and chondroitin 1200mg daily Cephalexin 500mg 1 tablet twice daily UTI Lacri-Lube lubricating eye ointment (paraffin liquid, paraffin soft): prn Applies at night Dry/sore eyes Nitrazepam 5mg: ½ a tablet at night ½ tablet when required Sleep prn (approx 2 times a week) Paracetamol SR 665mg: 2 tablets 2 tablets three times daily Pain tds Reboxetine 4mg: 1 tablet daily [Edronax ] 1 tablet daily anxiety/depre ssion Prochlorperazine 5mg Occasional use (approx 2 Nausea tablets per month) Budesonide/Eformoterol 1 dose twice daily Asthma 100/6mcg/dose Turbuhaler: 2 doses once daily Salbutamol 100mcg/dose Not often except in last week when feeling unwell Sertraline 100mg: 1 tablet daily 1 tablet daily anxiety/depres sion Prolia 60mg/ml (Denosumab) Every 6 months? Coloxyl with Senna 2 tablets daily Constipation Loperamide 2mg Rarely using Diarrhoea Rennie (antacid) Approx Once a week Reflux Case 2 Hypercalcaemia Calcium/vit D + hydrochlorothiazide Stones Bones Groans Thrones Psychiatric overtones Recent aspirin use (no PPI & and SSRI) Two antidepressants (anxiety since 1965) No oestrogen cream used Presentatie van Mark Naunton BPharm (Hons), MPS, MSHPA, PhD, AACPA 11
Case 2 I need one of these Son of case 2 Case 3 41 yrs Alcohol abuse Back pain Knee pain Neck pain Testicular cancer Concussion Chronic migraine PTSD Night terrors Mild dyslipidaemia Libido reduction Presentatie van Mark Naunton BPharm (Hons), MPS, MSHPA, PhD, AACPA 12
Case 3 Patient concerns Nausea Pain Nightmares Zolpidem wants to stop Libido reduction Prescribed Drug and Dose Frequency according to patient Purpose according to pt Acamprostate 333mg: 3 tablets bd 3 tablets twice daily Alcohol dependence Duloxetine 60mg: 2 tablets daily [Cymbalta ] 2 tablets daily Depression/An xiety Sodium valproate EC 500mg: 1 1 tablet twice daily Migraines tablet bd Prazosin 1mg: 3 tablet at night 3 tablets at night Nightmares [Minipress ] Naltrexone 50mg: 1 tablet daily 1 tablet daily Alcohol dependence Ibuprofen/codeine 200/12.8mg Approx 2 tablets three Pain times a day Paracetamol 500mg Approx 2-4 tablets per Pain week Cyproheptadine 4mg Occasional use Sleep Quetiapine 25mg: 1 tablet daily prn 1 tablet prn Anxiety Quetiapine XR 150mg: 1 tablet daily 1 tablet at night Depression/An xiety Prochlorperazine 5mg: 1 tablets Approx 2-3 times a Nausea three times daily prn week Zolpidem 10mg: 1 tablet nocte prn 1 tablet daily Sleep Vitamin B1 (Thiamine) 100mg: 1 1 tablet daily Supplement tablet bd Diazepam 5mg: 1 prn Approx 2 tablets per week Anxiety Oxycodone 5mg [Endone] Krill oil The good vitamin (contains: 50mg vitamin C, 50mg vitamin B6, 301.5mg Magnesium, 4mg Manganese and 2.5 mcg vitamin D) Severe pain 1 capsule daily 1 tablet daily Cramps Presentatie van Mark Naunton BPharm (Hons), MPS, MSHPA, PhD, AACPA 13
Case 4 Patient concerns Increasingly difficulty with breathing last 6 months it s different COPD CVA Depression AF Hypertension Dyslipidaemia GORD Hydrocortisone 1% cream: Applies 1-2 times Itch apply bd a day Omeprazole 20mg: 1 tablet 1 tablet daily Reflux daily [Losec ] Paracetamol/codeine Approx 4-6 tablets Pain 500mg/30mg: 2 tablets bd [Panadeine Forte ] daily Hydroxychloroquine 200mg: 1 1 tablet at night arthritis tablet daily [Plaquenil ] Dabigatran 150mg: 1 tablet bd 1 tablet twice daily Blood [Pradaxa ] Thinner Sertraline 100mg: 2 tablets 2 tablets each Depression daily [Xydep ] morning Sotalol 80mg: ½ tablet twice daily [Sotacor ] ½ a tablet twice daily Heart Tiotropium 18mcg: 1 capsule daily [Spiriva ] Oxycodone/Naloxone SR 40/20mg: 1 tablet twice daily [OxyContin ] Vitamin B1 (Thiamine) 100mg: 1 tablet daily [Betamin ] Ramipril 10mg: 1 capsule daily [Tritace/Tryzan ] 1 capsule daily Lungs 1 tablet twice daily Pain 1 tablet daily Alcohol use 1 capsule daily? Ezetimibe/simvastatin 10/10mg: 1 tablet daily [Vytorin ] Salbutamol MDI 100 1 tablet at night When required? Asthma mcg/dose Mometasone 1mg/g lotion When required Itchy scalp Swisse ultiboost immune 1 tablet daily (Olive leaf, Zn, Mg, Co, vit c and biflavonid extract). Diazepam 2mg When required (approx 3 tablets per month) Panic/anxiet y Loperamide 2mg [Diareze] Rarely using Diarrhoea Donnatab (contains hyoscyamine sulf 103.7mcg, atropine sulf 19.4mcg and hyoscine 6.5mcg) Approx 4 tablets per months Cramps Overview Presentatie van Mark Naunton BPharm (Hons), MPS, MSHPA, PhD, AACPA 14
Drs and Recommendations Psychological Reactance Valmer Study Presentatie van Mark Naunton BPharm (Hons), MPS, MSHPA, PhD, AACPA 15
Guidelines Gout Diabetes HPT GORD Presentation Presentation Presentation Diagnosis Diagnosis IHD OP Presentation Presentation Presentation Diagnosis Patient Real Life Evaluation Management obese Diagnosis Evaluation Management Renal impairment Wife has affair Impotent Evaluation Management Diagnosis Evaluation Management Alcoholism Renal failure Evaluation Son Suicide s Management Diagnosis Heart failure Evaluation Management Drs and Recommendations Hospital-acquired infections 1 in 11 (13% mortality) Up to 30% are considered preventable through hand washing Hand washing by doctors known to be poor (<50%) Grol and Grimshaw Lancet 2003; Girou BMJ 325 17 2002) Presentatie van Mark Naunton BPharm (Hons), MPS, MSHPA, PhD, AACPA 16
Medication Review Recommendations Klopfer Hosp Pharm 1990 85% (review of 23 studies) Leape JAMA 1999 99% (ICU) Gilbert 2002 MJA 42% (collaborative medication reviews) Dename J Am Pharm Assoc 2009 61% (diabetics) Wang HY Transplant Proc 2008 96% (renal unit) McCollum 2009 Am J Pharm Ed 32% (students) Davis Am J Geriatr Pharmacother 2007 69% (Veterans) Michaels J Am Pharm Assoc 2010 42-60% acceptance; 62-86% implemented Naunton 2003 JPPR 79% (post-discharge medication reviews) HMR Objectives Achieve safe, effective, and appropriate use of medicines by detecting and addressing medicine-related problems that interfere with desired patient outcomes Improve the patient's quality of life and health outcomes using a best practice approach Improve the patient's, and health professional s knowledge and understanding about medicines Facilitate cooperative working relationships between members of the health care team in the interests of patient health and wellbeing Presentatie van Mark Naunton BPharm (Hons), MPS, MSHPA, PhD, AACPA 17
HMR Objectives (in short...) Achieve QUM by fixing medicine-related problems Improve quality of life and health outcomes through best practice Improve everyone s knowledge and understanding about medicines Get the health care team working together to benefit patients Presentatie van Mark Naunton BPharm (Hons), MPS, MSHPA, PhD, AACPA 18
` Presentatie van Mark Naunton BPharm (Hons), MPS, MSHPA, PhD, AACPA 19
` Other Paid Programmes Presentatie van Mark Naunton BPharm (Hons), MPS, MSHPA, PhD, AACPA 20