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Medicines Management Programme
Regional Prescribers’ Forum
Cork University Maternity Hospital
November 7th 2013
Dr Helen Flint
National Lead Medicines Management
Office of the Nursing & Midwifery Services Director
Clinical Strategy and Programmes Directorate
Health Services Executive, Dublin, Ireland
Unsupervised sources of medicines
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Over-the-counter medicines
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Medicines purchased overseas
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Counterfeit medicines. They include products without active
ingredients, or with the wrong active ingredients, or with insufficient
active ingredients, or with fake packaging. Sometimes they contain
substitutes, or are diluted with foreign or toxic bodies, to increase the
quantity of the original medicine
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Medicines purchased on the Internet
Irish Medicines Board Patient Survey 2011
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Almost three in four of those surveyed claim to read product information (on the leaflet and
label) before taking a prescription medicine for the first time
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Among those who do not read the product information, the vast majority qualified this by
explaining that their GP or pharmacist give them the necessary information
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67% read the product information before taking an over the counter medicine for the first
time
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One quarter of adults (25%) use the internet as a source of information about medicines. Of
the 1 in 4 consumer who do go online 30% are attempting to diagnose health symptoms
(self diagnosis)
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Half (49%) of those surveyed always seek advice from a healthcare professional– typically a
pharmacist – before taking a new over the counter medicine
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GPs (68%) and pharmacists (25%) are by far the most trusted sources of medicines advice
Effect of patient payment status
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80% antibiotics prescribed by GPs
Recent study compared GMS with private
GMS 54 years: private 34 years
Antibiotics prescribed at 3,407 consultations
Private patients were 23% more likely to receive a prescription
for antibiotics overall
Private patients were more likely to receive a delayed or
deferred prescription
In general patient <65 years less likely to receive a prescription
?private patients present at a later stage or unwillingness to
return for a second visit due to cost
Authors suggest patient expectation
NMIC, 2011
Non-adherence
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“A worldwide problem of striking magnitude” (WHO, 2010)
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Improving adherence has become a priority
30-50% of patients do not take their medication for chronic
conditions as prescribed
Cost of non-adherence is a missed opportunity for treatment
gain
Unused or unwanted medicines £millions annually
75% reported a visit to community pharmacy in last 6 months
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Medication adherence
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Poor adherence and persistence in chronic disease
Poor persistence in prevention of osteoporosis
Medical model does not sit with the theory of concordance
Taking medicines according to the instructions
Unintentional drug misadventure e.g., nebulisers and inhalers
Completing the course of drug therapy
Drug may make the person feel unwell e.g., nausea, dizziness,
alteration of bowel habit, frequency of micturation
Drug may not improve the problem
May have problem swallowing
People may share medications
People may confuse medicines
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Women who stop taking their prescribed hormone tablets after
surgery to treat breast cancer are almost three times more likely
to have their cancer reoccur
1400 Irish women
Up to 30% of women will discontinue hormone treatment, with
another 20% not taking as many as one in five of their doses
Early identification of women experiencing side-effects, the
availability of effective supportive pharmacologic and
psychological care, and the timely switching to alternative
hormonal therapies could make a significant impact on patients
adhering to their medication, and thereby improve their chances
of living longer”
The full paper is available from the British Journal of Cancer at:
http://www.nature.com/bjc/journal/vaop/ncurrent/full/bjc2013518
a.html
Key performance indicators
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Specific and measurable elements of practice that can be used to
assess quality of care
Act as flags or alerts
Capture trends
Inference about quality
Medicines Management pilot Q4 2013
Medicines Reconciliation
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The process of obtaining an up-to-date and accurate medication
list that has been compared to the most recently available
information and has documented any…….
Resulting in: “a complete list of medications, accurately
communicated” www.ihi.org
Discrepancies
Changes
Deletions
Additions
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9
Non-pharmacological interventions
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Patient expectation from Doctors visit is treatment: most
commonly a prescription; medicines are regarded as
something that will fix the problem
Other interventions are non-reimburseable in Ireland
Dietary i.e., specialist drinks, probiotics, supplements &C
Counselling
Breathing re-training
Relaxation and teaching coping and adaptation strategies
Heat and cold
TENS (Transcutaneous Electrical Nerve Stimulation)
Behavioral symptoms associated with dementia: range of
interventions
Acupuncture
Medicines Management Programme:
over-arching aim
“Our vision is that people everywhere have access to the
essential medicines they need; that the medicines are safe,
effective and of assured quality; and that they are prescribed and
used rationally”
Essential Medicines and Pharmaceutical Policies (WHO, 2010)
National Medicines Care Programme
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IMPROVE MEDICINES SAFETY
 Reduce medicines-related hospital admissions, morbidity and mortality
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ENSURE PATIENTS HAVE ACCESS TO THE MEDICINES THEY NEED
 Access to medicines based on need and is evidence-based
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REDUCE COST
 Ensure rational prescribing for the five most expensive drug groups
 Introduce systems for switching to equally effective and less expensive
alternatives where opportunities arise
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IMPROVE MEDICINES ADHERENCE
 Ensure patients are on the right medicines
 Ensure patients understand the rationale for the medicine choices
 Support patients with taking their medicines correctly to improve health and
reduce wastage
‘Preferred’ Medicines
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Although there are no head-to-head trials, clinical experts do not
consider there to be clinically significant difference between the
currently authorised agents
Guidelines for good medication management would involve
selecting the cheaper of two options
In line with list of interchangeable drugs in new pharmacy
system
Open discussions with patient representatives
Preserve clinical freedom: exception rather than rule
Preferred Medicines
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April 2013 Medicines Management Programme identified both
the ‘preferred’ statin and PPI for Ireland
Traditionally account for @20% expenditure under the GMS
scheme
PPIs used for the management of various GI conditions for
many years
No direct comparative efficacy studies: however repeated
scientific reviews suggest that any differences in efficacy noted
are of negligible clinical relevance
The MMP has indicated that lansoprazole should be
considered as the PPI of first choice and switching from
other PPIs could save over € 23 million per annum
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simvastatin is the most cost-effective statin and therefore should
be considered as the statin of first choice;
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An alternative statin should be considered for patients on
concomitant medications with a potential to interact with
simvastatin and those where simvastatin is contraindicated;
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Full prescribing information is available on
www.medicines.ie/www.imb.ie.
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As part of the Preferred Drugs initiative the Medicines
Management Programme (MMP) is considering two further drug
classes;
selective serotonin re-uptake inhibitors (SSRIs)
serotonin noradrenaline re-uptake inhibitors (SNRIs)
These drug classes are being reviewed with the aim of
recommending the preferred SSRI and SNRI to prescribers in
the first quarter of 2014
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The SSRIs being considered for inclusion in the
Preferred Drugs initiative are:
citalopram
escitalopram
fluoxetine
fluvoxamine
paroxetine
sertraline
These drugs are used for a wide range of conditions
including depression, generalised anxiety disorder,
panic disorder, etc.
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The SNRIs for consideration are:
venlafaxine
Duloxetine
The MMP now invite submissions from stakeholders to
inform the selection process which will consider a range of
criteria including licensed therapeutic indication(s), clinical
outcome data, clinical guidelines, cost, patient factors and
prescribing trends in Ireland.
Submissions should be made to: The National Centre for
Pharmacoeconomics, St. James’s Hospital, Dublin 8 or
[email protected]
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The Medicines Management programme (MMP) has recently
reviewed prescription data from the PCRS database for
pregabalin and gabapentin for 2012;
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There was a steady rise in pregabalin prescribing with a monthly
ingredient cost of pregabalin to the PCRS of € 2 to 3 million; this
represents a 10-foldincreased cost compared with gabapentin
ingredient cost during the same time period.
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Pregabalin is licensed in the EU for
the treatment of adult neuropathic pain,
adjunctive therapy in adults with partial seizures (with or
without secondary generalisation) and
treatment of generalised anxiety disorder in adults.
The dose range is 150- 600mg/day (given in 2 or 3 divided
doses)
Evidence of sub-optimal prescribing
In the absence of overwhelming evidence of superiority of one
drug over another, the review states it would seem sensible to
use the lowest cost agent first
Source of concern with algorithms?
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Irish health service is not used to working within strict
parameters
USA: Funding depends on adhering to standards (BTA)
UK: Funding directed by NICE which has statutory powers
(BTE)
The argument is “medicine by numbers”
Decisions made clinicians who are used to debating
Declarations of interest: Irish infrastructure includes funding by
pharmaceutical industry
Target areas for safe, effective and costeffective prescribing
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Generic medicines
Oral nutritional supplements
Proton pump inhibitors (PPIs)
Statins
Pregabalin (f an average of 10 patients in every practice in NI.
were switched from a two twice daily dose of pregabalin to a
one twice daily dose (of double the strength) this could save
almost £3 million for the health service)
New oral anticoagulants
HSE Funding of New Medicines (evidence-based)
Ace-inhibitors (angiotensin-converting enzyme) ARBs
(angiotensin receptor blockers: hypertension, heart failure &C)
New oral anticoagulants
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1% adults have atrial fibrillation
Dabigatran (pradaxa) rivaroxaban (@Xarelto)
apixaban (Eliquis) appear to be at least as efficacious
and safe as warfarin
No antidote to reverse
Patients should have creatinine clearance checked
(Lancet Neurol. 2012; 11: 1066-1081)
Cost effectiveness