Quality prescribing in general practice Jana Mrak, Alenka Premuš Marušič, Mojca Prislan, Brian Godman, Jurij Fürst EUMASS, Ljubljana, 10.6.2016

DISCLOSURE Stock shareholder: AstraZeneca, Abbot Laboratories, Abbivie Inc., Novo Nordisk, GlaxoSmithKline, Merck & Co Inc.

ZZZS efforts in the field of quality prescribing during last years Development task - Quality prescribing in general practice (8 quality indicators issued), May 2011 Systematic presentation of quality indicators in the regions/ Health Community Centers, 2012 New development task - Quality prescribing in general practice (clinical pharmacists as members of general practitioner’s team), November 2012 too December 2015 Systemic implementation of clinical pharmacists at a primary care level through a General agreement, starting in 2016

Aim and objectives of the development task - Quality prescribing in general practice 2012 - 15 to implement continuous improvement of prescribing (safety and efficacy of treatment with medicines) Objectives: A systematic review of less appropriate medications for elderly patients (through lectures) A systematic review of medications in patients with polypharmacotherapy (5 or more different medications) Reduced growth in polypharmacotherapy

Clinical pharmacist Refers a patient Reviews patient’s pharmacotherapy Issues a written report for the GP General practitioner: Refers a patient Adjusts or modifies patient’s pharmacotherapy in agreement with the patient Regular meetings of physicians and clinical pharmacists to share expertise and experiences.

Model introduction timeline From November 2012 till March 2014 (first part): Region Murska Sobota From April till December 2014 (second part): Health Community Center Ljubljana. From January till December 2015 (third part): Region Murska Sobota, Health Community Center Ljubljana Health Community Center Idrija.

Scientific program approved by the Medical Chamber of Slovenia First part: PRISCUS list Second part: Region Murska Sobota: medications during pregnancy, newer diabetes medicines , some herbal preparations Health Community Center Ljubljana: PRISCUS list Third part: Region Murska Sobota: beta blockers, ivabradine, ranolazine, trimetazidine; medicines for dementia, asthma & COPD medications, lipid-lowering drugs Health Community Centers Ljubljana and Idrija: newer anticoagulants, newer diabetes medicines, some herbal preparations

Results of model implementation 192 group meetings (clinical pharmacist and physicians) 1097 weekly afternoon sessions (clinical pharmacist) 3640 pharmacotherapy reviews which uncovered (LexiComp database): 944 X-drug interactions (these agents are generally considered contraindicated - avoid combination) 5721 D-drug interactions (assessment should be conducted in order to determine whether the benefits of such combination outweights the risks - consider therapy modifications)

No. of persons with polypharmacotherapy* *Polypharmacotherapy is defined as 5 or more active ingredients (ATC level 4) prescribed at the same time.

Physicians endorsed the development task and supported cooperation with clinical pharmacist. (Questionnaire at the end of each part of development task.)

Age of the respondents 2014* (1.4. – 31.12.); 2015*(1.1. – 31.12.)

Workplace of the respondents 2014* (1.4. – 31.12.); 2015*(1.1. – 31.12.)

Group meetings continuation 2014* (1.4. – 31.12.); 2015*(1.1. – 31.12.)

Weekly afternoon sessions continuation 2014* (1.4. – 31.12.); 2015*(1.1. – 31.12.)

Independent information on medicines 2014* (1.4. – 31.12.); 2015*(1.1. – 31.12.)

Lessons learned Local organization is convenient and well accepted by all participants including patients. Availability of clinical documentation enables more accurate pharmacotherapy reviews. Regular meetings of physicians and clinical pharmacist were in the survey among participants rated as necessary. Obvious benefits for individual patients (No of X and D interactions found).

Systemic implementation of clinical pharmacist on primary care level Partners in General agreement have agreed about the gradual implementation across Slovenia: During 2016 in regions Murska Sobota, Ljubljana, Maribor, During 2017 in regions Kranj, Celje, Ravne na Koroškem, During 2018 in regions Novo mesto, Krško, Nova Gorica, Koper. According to General agreement - clinical pharmacists will be employees of Health Community Centers with the possibility of having session in private clinic with concessions. After completion of the implementation there should be 17,57 field territory equivalents (FTE) of clinical pharmacists : Yearly costs of 40.998 Euro per FTE per year or 720.335 Euro per year all together.

Thank you for your attention!