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Efficiency improvement of primary care prescription by physicians - pharmacists cooperating in quality circles Ruggli M.1, Nyffeler R. 3, Duay B.4, Repond C.4, Buchmann M. 4, Bugnon O.1;2 1 Swiss Association of Pharmacists, Liebefeld, Switzerland 2 Community Pharmacy of the University Medical Outpatient Clinic, Lausanne, Switzerland 3 Medical Association of Primary Care Physicians, Fribourg, Switzerland 4 Pharmaceutical Association of Pharmacists, Fribourg, Switzerland Schweizerischer Apothekerverband Société Suisse des Pharmaciens Società Svizzera dei Farmacisti Contact address: [email protected] AIMS OF THE STUDY: In 1997 the Medical and Pharmacist's associations of Fribourg, Switzerland, launched a pilot project of cooperation between physicians and pharmacists: 6 pharmacists each coached a quality circle with a total of 27 physicians. The circles worked on 17 therapeutic groups comparing the risk/benefit of drugs, discussing prescribing patterns and trying to agree on treatment options based on two objectives: improving the quality and efficiency of care. After the encouraging results reported in 1999 and 2000 1, the new assessment is based on the years 1999 to 2002. Work process Continous quality improvement of prescription CONCEPT OF PHYSICIANS-PHARMACISTS QUALITY CIRCLES: The quality circles are stable groups of 4 to 10 physicians with one (or more) pharmacist as moderator. Based on the physicians’own current prescription data, pharmacists and physicians are involved in the continuous quality improvement of prescribing practices, thanks to education on guidelines, evidencebased medicine and pharmacoeconomy. 1. Prescription data 7. Assessment of the (benchmarking per physician and therapeutic class) results and improvements 2. Education on guidelines, 6. Check on the impact Evidence-based medecine and pharmacoeconomy. of the consensus 5. Application of the 3. Analysis of prescription attitudes in consensus RESULTS: comparison with scientific and economic data and search for alternatives in drug market 4. Consensus of each quality During these 4 years the overall cost of drugs increased by 39% in the control group (80 comparable general practitioners, but not involved with pharmacists in quality circles) and 30% in the 6 circles (figure 1) circle 145.0 139.0 Drugs' cost evolution (Index) 140.0 +6.4% 135.0 In 2002 this 9% increase difference represents a saving of about 48’000 CHF per physician (circa $ 37’000.- in August 2004) 130.6 +7.3% 130.0 130.0 121.7 125.0 126.7 +2.6% 120.0 +10.0% 115.0 +21.7% 115.2 110.0 105.0 +15.2% Control group Fig. 1 cost evolution between 1999 and 2002 Quality circles for quality circles and control group 100.0 1999 2000 2001 2002 The physicians working with pharmacists changed their prescription patterns in a lasting way, as can been seen in 2002: 0.0 control group quality circles control group quality circles Fig. 2 Generics prescription for antibiotics and NSAIDS 10 5 0 Control Group Quality circles Control group Quality circles Fig. 3 Prescription frequency of antibiotics and NSAIDS 29.8 15.0 2002 17.7 20.3 20.0 20.9 25.0 2001 23.8 25.3 COXIBS GLITAZONES 10.0 5.0 1.7 3.5 15 30.0 2000 5.2 20 35.0 13.8 11.3 10.5 25 A2A 15.9 16.7 17.3 30 2002 More reasonable influence of marketing and advertising: less coxibs (10.5 vs 17.3%), A2A (23.8 vs 29.4%) or glitazones (3.5 vs 5.2%) (fig 4). 2.5 5.0 35 ANTIBIOTICS 25.2 38.9 22.6 10.0 40 NSAIDS % of packages from specific pharmacological classes 20.0 19.3 25.0 19.7 25.0 21.1 NSAIDS 30.0 15.0 2002 45 28.4 35.0 2001 33.5 41.4 ANTIBIOTICS 2000 17.5 40.0 38.5 45.0 13.0 Percentage of generics' packages 50.0 % of patients treated with a specific drug group 46.9 prescription (42 vs 25% for antibiotics, 47 vs 22% for NSAIDs) (fig 2) 37.8 Higher rate of generics Qualitatively more adapted frequency of prescription: lower for antibiotics (25.2 vs 28.4%) and NSAIDS (37.8 vs 40.1%) (fig3) 40.1 0.0 control group Quality circles Control group Quality circles Control group Fig. 4 : Proportion of prescribed coxibs, A2A and glitazones CONCLUSIONS: This study confirmed the added value of physicians-pharmacists quality circles as local care managing projects for the improvement of drug prescription efficiency.Quality circles at a local level succeed in promoting the use of evaluated generics and other cost- and outcome-effective activities including evidence-based analyses of new drugs, interdisciplinary continuing education on the rational use of drugs, implementation at a local level of national or international guidelines, continuing and comparative follow-up of the consensus implementation. Community pharmacists can influence physicians’ attitudes and are efficient partners in care management. The project has now disseminated throughout Switzerland and has been acknowledged by politicians and major private insurers. A financial incentive was granted for the pilot project and a national negotiation started in 2004. REFERENCES 1 Increase of generics prescription by physicians involved with pharmacists in quality circles, O. Bugnon, I. Gremaud-Tinguely, C. Repond, J. Carrel, D. Muscionico, R. Nyffeler and M. Buchmann, FIP 2000 Quality circles