Drugs Aging DOI 10.1007/s40266-016-0353-6
REVIEW ARTICLE
Development of Clinical Pharmacy in Switzerland: Involvement of Community Pharmacists in Care for Older Patients Kurt E. Hersberger1 • Markus Messerli1
Springer International Publishing Switzerland 2016
Abstract The role of the community pharmacist in primary care has been undergoing change in Switzerland in parallel to international developments: it has become more clinically and patient oriented. Special services of community pharmacists to older patients taking long-term or multiple medications, discharged from hospitals or experiencing cognitive impairment or disability have been developed. These services require more clinical knowledge and skills from community pharmacists and are based on, for example, ‘simple or intermediate medication reviews’ focused primarily to improve medication adherence and rational drug use by a patient. Reflecting the new role of community pharmacies, this article describes the current services provided by community pharmacies in Switzerland, e.g., ‘polymedication check’, ‘weekly pill organizer’, and ‘services for chronic patients’, as well as new Swiss educational and reimbursement systems supporting development of these services. In the international context, involvement of community pharmacists in patient-oriented care is growing. This review summarizes positive and negative experiences from implementation of community pharmacy services in Switzerland and provides examples for the development of such services in other countries.
& Kurt E. Hersberger [email protected] 1
Pharmaceutical Care Research Group, Department of Pharmaceutical Sciences, University of Basel, Klingelbergstr. 50, 4056 Basel, Switzerland
Key Points For chronic patients new community pharmacistled services have been developed and implemented in Switzerland (e.g. medication review, weekly pill organizer filled by the pharmacy or structured triage algorithms for specific care situations). Clinical pharmacy knowledge and skills are essential also for community pharmacists when providing pharmaceutical care to ambulatory patients. The Swiss Association of Pharmacists strengthened the efforts in the development of clinical pharmacy services, mainly through own initiatives and sponsoring of four 50% professorships in Basel and Geneva.
1 Introduction The Swiss healthcare system is characterized by both liberalism and federalism (see Box 1). The environment in which the 1764 community pharmacies operate for eight million inhabitants is fairly competitive: dispensing physicians, mail order pharmacies, high proportion of about 30 % of chain pharmacies, no restriction to opening new pharmacies, and continuous pressure on pharmacists’ margins pose distinct problems for the development of clinical pharmacy services provided through community pharmacies. In this context, the Swiss Association of Pharmacists has adapted international developments and initiated an in-depth reform of the profession.
K. E. Hersberger, M. Messerli
Box 1 The Swiss healthcare system Each person living in Switzerland is obliged to purchase mandatory health insurance from an authorized insurer. They are free to choose their healthcare physician and have unlimited access to general praconers and specialists. There is no formal gatekeeping system in place. Almost half of the populaon (46 %) holds a special insurance policy where they receive premium reducons in exchange for agreeing to join one of the 90 exisng managed-care networks such as Health Maintenance Organisaons, family-doctor gatekeeping schemes, Independent Pracce Associaons, or Preferred Provider Organisaons. The naonal healthcare system is individually regulated by the cantons and 26 different systems have to be considered. Notably, in 16 cantons, physicians may dispense drugs directly to their paents (dispensing physicians). Ambulatory services are largely provided by physicians operang as independent/single-person pracces. In addion, ambulatory services are also provided by outpaent departments of public and private hospitals and by managed-care-style organisaons. Similarly, a liberal regulaon of medicines supply allows for dispensing physicians, pharmacy chains, mail order pharmacies, and supply of some over-the-counter drugs outside of a pharmacy [1].
In the early 1990s, pharmaceutical care was introduced in community pharmacy practice, and emphasis was given to providing patient-centered care and cognitive pharmaceutical services [2]. A postgraduate education program and obligatory continuous education were launched together with changes to pharmacists’ remuneration, which links payments to services delivered and not only to the volumes of medicines dispensed (see Table 1).
2 Initiatives by the Swiss Association of Pharmacists As the combination of rising multi-morbidities and health workforce shortages for medical professionals becomes more pronounced, especially with general practitioners
(GPs), pharmacists hold the potential to provide constructive support in medication management and the coordination of care. While efforts are made to re-orient pharmacy practice towards a focus on quality of care, policies allowing doctors to dispense drugs in some Swiss regions work against and create perverse competition in primary care and hamper coordination among networks of healthcare providers. Regardless of these barriers (or eventually induced by them), the Swiss Association of Pharmacists strengthened the efforts in the development of clinical pharmacy services, mainly through a quality-care program named QMSPharmacy (Quality Management System for Community Pharmacies), different campaigns (e.g., screening for cardiovascular risks, chronic obstructive pulmonary disorder, colorectal cancer, melanoma, microalbuminuria), the
Table 1 Services supporting rational and cost-effective drug use provided by Swiss community pharmacies: remuneration in Switzerland and according fees (examples) Pharmacy service
Description/activities
Fee (EUR) [1]
Delivery check
Each prescription: check of medication history for interactions and accumulation (including self-medication)
3.00
Drug check
Each dispensed item
4.00
• Check for: eventual possibility of repeat dispensing, dosage, limitations, interactions, risk factors, contraindications, misuse • According activities: patient counseling, eventual contact with prescriber, choice of optimized package size, immediate provision Generic substitution
Pharmacists have been allowed (and are officially invited) to substitute generic drugs for originals with the patient’s agreement and when the doctor does not oppose it
40 % of the difference to the original
Only at first delivery, a fee is available Emergency fee
To cover the extra charges of the pharmacist on emergency, night, and weekend duty, requested per patient and visit
16.00
Supervision of directly observed treatment
When a patient takes drugs in the pharmacy under the pharmacist’s supervision (e.g., opioids, disulfiram)
10.00
Adherence fee
For preparation of a weekly pill organizer/blister pack for an outpatient with a chronic condition and taking at least 3 different drugs
20.00/week
For patients on C4 prescribed drugs taken over C3 months
45.00
Polymedication check
If patient agrees, but independently from the prescriber
Development of Clinical Pharmacy in Switzerland
development of smoking cessation programs, and, recently, by a new telemedicine service called netCare (see Box 2). In addition, the association saw the need to change the basic education and to foster clinical training during the 5-year pharmacy curriculum (3-year Bachelor in Pharmacy Sciences/2-year Masters in Pharmacy). They became engaged in sponsoring 50 % professorships, two in Basel and two in Geneva. This funding, over a period of 5 years, has currently been translated into sustained installation of the four professorships in clinical pharmacy and pharmacy practice by the respective universities. The patient-oriented teaching was significantly improved and each of the four professorships showed impressive development of the research group with scientific output. Similarly, the introduction of ‘quality circles’ supported by the association provides an example of a collaboration to improve physician-prescribing behavior towards evidence-based policies. Currently, about 80 quality circles are active across Switzerland. They bring together five to eight physicians and pharmacists to develop collective evidence-based guidelines and to put these recommendations into practice. While it has been shown that they improve quality and efficiency, the effects on cost savings have been varied [3, 4]. While some insurers have already financially supported quality circles where they achieve savings, efforts to provide incentives for improved quality in prescribing and medication management are likely to become increasingly worthwhile for responding to changing health needs that are driven by an aging population and rising chronic disease [1].
3 Polymedication Check Since 2010, Swiss community pharmacies can offer a ‘polymedication check’ (PMC) to patients on four or more prescribed drugs taken over C3 months. Referring to the different types of medication reviews, defined by the Pharmaceutical Care Network Europe, the PMC is identified as an ‘intermediate’ medication review (see Box 3). Information is available from the medication history, which is mandatorily kept in Swiss community pharmacies, and from a structured patient interview. The check focuses on adherence problems, patients’ knowledge, and handling problems. Pharmacists are instructed to use open questions to detect pharmaceutical care issues and to decide on the need for intervention. However, they must prioritize the problems detected and document in a very simple way if the patient needs counseling (yes/no), has adherence problems (yes/no), if the pharmacist has to consult with the GP, refer the patient, or suggest any other recommendations or interventions. At the end of the interview, the patient signs the documentation form and the pharmacy can charge a fee of 45 Euros to the health insurer. Evaluations of the service showed that simplifications in therapy plans and improvement of knowledge provided by pharmacists are highly appreciated. Patients need wellfounded answers. An example is the frequent question on the best timing of medication intake. As polypharmacy has developed in each patient over a long period of time, the review of the intake schedule becomes essential and altering the timing of the intake may improve therapeutic outcomes. While some medicines need to be taken
Box 2 netCare: a new telemedicine service in Swiss pharmacies netCare allows paents to get a first structured triage based on decision trees for the most common diseases. The triage can result in (a) treatment by the pharmacist, (b) referral to a physician, or (c) asking the telemedicine doctor’s help by video from the pharmacy with eventual provision of a prescripon directly transmied to the pharmacy. The service comprises a follow-up aer 3 days to evaluate if the treatment is efficient. The project started in April 2012 with 200 pharmacies and a study will evaluate the efficiency, safety, and efficacy of the service [5].
Box 3 Types of medicaon reviews, defined by the Pharmaceucal Care Network Europe [6] Simple medicaon review (only Based on drug history, refill data one source of informaon) Intermediate medicaon review Type A: Based on drug history, refill data, AND paent interview (two sources of informaon) Type B: Based on drug history, refill data, AND clinical data (diagnoses, laboratory data) Advanced medicaon review Based on full informaon from drug history, paent interview, (three or more sources of AND clinical data informaon)
K. E. Hersberger, M. Messerli
separately (e.g., bisphosphonate, L-thyroxin), most longterm medication can be taken at the same time, preferably in the morning and avoiding doses to be taken at lunch. Thus, when performing medication use reviews, knowledge of disease and chronopharmacology is important. Pharmacists have to take note of the pharmacokinetic properties and the ‘forgiveness of drugs’ to optimize therapeutic coverage and to cope with risks of non-adherence. Skills in disease management are important and chronotherapy is now also an emerging concept [7]. Implementation of such cognitive services provided by a pharmacist is known to be very challenging [8]. The same is true for Swiss community pharmacies. Implementation of the PMC is low and after 3 years only about three checks per pharmacy per year were registered, with a large majority of pharmacies not offering this service. Focus group discussions revealed ‘‘no time’’, ‘‘not my responsibility, ‘‘patients do not understand the service’’, and ‘‘service already included in validation of prescription’’ as barriers to providing a PMC [9]. Pharmacists become highly motivated after first experiences, thus, ‘‘the first is the worst’’. In an ongoing randomized controlled trial (NCT01739816), we are observing 450 patients recruited from 70 study pharmacies. The primary outcome focuses on the improvement of adherence after the PMC (using the medication possession ratio and patients’ interviews). The second outcome is the number of unplanned consults with a physician or hospitalization. In addition, we evaluated various aspects of self-management. First results have proven the feasibility of this service and they reveal a wide range of pharmaceutical care issues to be addressed in such a counseling session.
4 Weekly Pill Organizer Through the PMC, pharmacists can evaluate a patient’s need for a weekly pill organizer (WPO). Either the pharmacy can provide a pill box to be filled by the patient or caregiver himself, or if the patient agrees and is taking at least three different medicines, the pharmacy can prepare a pill organizer/blister pack. This additional service is also remunerated by 20 Euros/week. Although evidence of the impact of dose reminder systems is still weak and our recent systematic review revealed important research gaps [10], we consider this service very important. Currently, most WPOs filled in by a pharmacy are dispensed upon a prescription of the physician. Because about ten patients per pharmacy receive a drug reminder system regularly from their pharmacy, pharmacists seem to be much more open to such a service than to the more challenging PMC. However, preparation of a WPO requires repeated
Fig. 1 Workflow dose-dispensing service [19]
medication reviews. Figure 1 shows the workflow: first, at initiation to screen for non-adherence problems; second, to find the adequate solution(s) for the patient and in case of a drug reminder system being the agreed intervention, the best configuration of a patient’s regimen into the available (in general, four) intake times. Very shortly after the initiation of the service, a follow-up is needed, which can be done by phone. Later, either in a 6-month sequence or at each significant change of the therapy (namely after hospital discharge), a next medication review becomes due.
5 Services for Chronic Patients through Swiss Community Pharmacies In general, patients visit a pharmacy without advance announcement and the pharmacist provides counseling in an ad hoc situation. The pharmacist reacts to the patient spontaneously and counsels at the counter, without any further preparation. This setting does not provide privacy or the possibility to switch to a counseling room. Figure 2 summarises the different services provided by community pharmacies in a patient’s journey: the patient attends the pharmacy the first time with a new prescription for longterm medication and receives adequate instructions (A). Currently, there is no special service implemented, such as the new medicines service in the UK [11]. The new medicine is commonly evaluated by the GP after 1 month and at that time he/she can prescribe a repeat prescription for up to 12 months (B). Thereafter, the patient will show up regularly to receive a refill in the pharmacy (D) or to request over-the-counter medicines to treat minor illness
Development of Clinical Pharmacy in Switzerland Fig. 2 Journey of a chronic patient according to ad hoc or planned activities of a community pharmacist. ADE adverse drug event, GP general practitioner, H hospital, OTC over-the-counter medicine
(C), or with a question (E) concerning a manifest or potential drug-related problem. The patient will see his/her GP for a renewal of the repeat prescription or for an eventual change (F) of the prior treatment plan only after 6 months or 1 year. All these situations might prompt a deepened evaluation of the patient situation. Hereby, the ad hoc counseling evolves to structured pharmaceutical care services. They are mostly planned and can comprise an assessment of patient outcomes (V), a medication review (W) triggered by the questions of the patient, or a telephone interview as a follow-up of the therapy change (X). With respect to seamless care, reconciliation of therapies (Y) around a hospital stay represents another very relevant service and for disabled patients even a home medication review after discharge (Z) might be adequate. Currently, Swiss community pharmacists could, in all situations C–G, perform a PMC and receive remuneration. Therapy monitoring (V) by the pharmacist is not systematically foreseen. Still, the measurements of blood pressure, biomarkers for diabetes mellitus patients, or even lipid values are frequently offered. In general, these services are paid by the patient. However, accredited pharmacies following regular quality controls may perform prescribed testing by use of capillary blood and receive the standard payment for laboratory testing. There exist other services with distinct responsibilities, which are not (yet) covered by a specific fee. For example, when a refill prescription is expired, the pharmacist is also allowed to dispense a long-term medicine in advance to avoid interruption of the therapy (e.g., dispensing of phenytoin for a home resident whose neurologist is on holidays). In well-defined situations, even dispensing
without a prescription is permitted, according to a guideline that clearly specifies good practice with adequate documentation. Examples are replacement of expired medicine, salbutamol inhaler in the case of an asthma attack, and glyceryl trinitrate for angina.
6 Discussion Targeting individuals and not a population or society as a whole is a key concept of pharmaceutical care that can be viewed as an individualized service of pharmacists delivered to a distinct patient. Very recently, the Pharmaceutical Care Network Europe redefined the term pharmaceutical care as ‘‘the pharmacist’s contribution to the care of individuals in order to optimize medicines use and improve health outcomes’’ [12]. These services contain various contributions of pharmacists in patient-oriented care and the provision of medication reviews by pharmacists on different levels: simple, intermediate, and clinical. They are not subject to a specific setting: pharmacists possessing clinical knowledge and skills can provide pharmaceutical care when working in community pharmacies, within or for nursing homes or in hospitals. ‘Pharmaceutical care’ thus represents a broad concept of the involvement of various pharmacists in the optimization of patients´ pharmacotherapy in different settings of care. In community pharmacies, multiple-care issues can be addressed and relevant interventions are feasible. Mehuys [13] listed possible roles for community pharmacists when dealing with older patients with chronic diseases. In addition to drug–drug interactions, non-adherence, and
K. E. Hersberger, M. Messerli
deficient knowledge of patients, he also listed practical problems with drug taking such as difficulties with vision 32 %, blister opening 12.1 %, tablet swallowing 14.8 %, tablet splitting 29.7 %, and distinguishing between different drug packages 23.4 %. All of these drug-related problems are often supposed to be minor, but they might significantly impede the outcomes of a therapy. Potentially inappropriate medication (PIM) use in the older population is very prevalent in Switzerland as well. A recent study [14] revealed lower prevalence rates of PIM use in older managed-care patients compared with patients outside a managed-care plan (18.6 vs. 21.1 %). Hence, irrespective of belonging to a managed-care health plan, there is large room for improvement in PIM use. In Switzerland, repeat prescribing for a maximum of 12 months is allowed and such prescriptions currently constitute nearly 75 % of all items dispensed [15]. Hence, community pharmacies assume very responsible roles in the care of chronic patients. The recently introduced PMC is therefore a very important activity. More research, especially on the implementation and introduction of new remunerated services (such as a specific medication review after hospital discharge, telephone follow-up after changes of the therapy plan) is much desired. In addition, interprofessional collaboration should be fostered and obvious barriers such as drug-dispensing physicians need to be restricted. Because Swiss pharmacists are allowed to start a drug reminder system after such a PMC, delivery of a dosedispensing service poses multiple issues that are typically part of clinical pharmacy services. Often, the therapy plan needs to fit with the predefined options of a pill box and not all medicines can be dispensed because of stability problems [16]. Transitions of care imply changes in the level, location, or providers of care. Community pharmacies are very often the first of all healthcare providers involved after hospital discharge. Reconciliation of therapies is much more than a puzzle game! When reconciliation is seen as the starting point for a structured pharmaceutical care service and is bundled with interventions aimed at improving care transitions post-discharge, healthcare use may be reduced [17]. Mulhem observed 24–48 h after discharge non-adherence in 20 % of the patients [18]. Thus, a close follow-up is important and a simple telephone follow-up could easily be performed. However, when counseling potentially nonadherent patients, challenging problems could arise. Examples are action to be taken when one or two doses are missed, how to restart therapy after a drug holiday, and information on the risk of rebound effects when medication is immediately stopped. The basics of clinical pharmacy knowledge and skills are essential also for community pharmacists to address all
these issues, and specific knowledge is needed to perform clinical services for an individual patient. In fact, community pharmacists providing cognitive services (e.g., motivational interviewing) are in need of much more training in clinical pharmacy issues related to patient care in this specific population to become adequately skilled. However, patient outcomes have yet to be shown to be improved by the new services to be sustainably integrated into the Swiss primary care setting. Undergraduate teaching on the basics of patient care must be followed by postgraduate training. Currently, different university-based courses are in preparation (e.g., Certificate of Advanced Studies in Clinical and/or Hospital Pharmacy in Geneva and Basel).
7 Conclusion The involvement of community pharmacists in patient care in Switzerland is rising. The PMC in the format of an intermediate medication review is a promising new service. We need to foster patient-oriented education and training and to closer link hospital and community pharmacists through collaborative initiatives for postgraduate education. Strengthening of research on a local as well as an international level is essential to develop, implement, and continuously improve clinically oriented services provided also by community pharmacists. Acknowledgments The authors thank Emily Schultz from the Sustainability Research Group at the University of Basel for helpful comments in the preparation of this manuscript. This article is based on a presentation at the 42nd European Society of Clinical Pharmacy Symposium on the Implementation of Clinical Pharmacy Practice: Research, Education and Management, held in Prague, Czech Republic, October 2013. Compliance with ethical standards Conflicts of interest
The authors have no conflicts of interest.
Funding No sources of funding were received for the preparation of this article.
References 1. OECD reviews of health systems: Switzerland 2011 [cited 2014 03.03.2015] (Ref: OECD/WHO (2011). Geneva: OECD Publishing; 2011. doi:10.1787/9789264120914-en). Accessed 2016 Jan 30. 2. Sa´ez-Benito L, Fernandez-Llimos F, Feletto E, Gastelurrutia MA, Martinez-Martinez F, Benrimoj SI. Evidence of the clinical effectiveness of cognitive pharmaceutical services for aged patients. Age Ageing. 2013;42(4):442–9. 3. Guignard E, Bugnon O. Pharmaceutical care in community pharmacies: practice and research in Switzerland. Ann Pharmacother. 2006;40(3):512–7.
Development of Clinical Pharmacy in Switzerland 4. Niquille A, Ruggli M, Buchmann M, Jordan D, Bugnon O. The nine-year sustained cost-containment impact of Swiss pilot physicians-pharmacists quality circles. Ann Pharmacother. 2010;44(4):650–7. 5. Ruggli M, Erni P. netCare: a new telemedicine service in Swiss pharmacies 2012 [03.03.15]. Available from: http://www.pcne. org/conferences/wc2013/Abstracts/4-Ruggli.pdf. Accessed 2016 Jan 30. 6. Griese-Mammen N, Leikola S. Sliema, Malta: Pharmaceutical Care Network Europe; 2014. Available from: http://www.pcne. org/upload/files/28_Malta_MR_report.pdf. Accessed 2016 Jan 30. 7. Kaur G, Phillips C, Wong K, Saini B. Timing is important in medication administration: a timely review of chronotherapy research. Int J Clin Pharm. 2013;35(3):344–58. 8. Houle SKD, Grindrod KA, Chatterley T, Tsuyuki RT. Paying pharmacists for patient care: a systematic review of remunerated pharmacy clinical care services. Can Pharm J. 2014;147(4):209–32. 9. Messerli M. Polymedication-check: first experiences with a new reimbursed cognitive service 2011 [poster presentation]. Available from: https://pharma.unibas.ch/fileadmin/pharma/redaktion/ groups/Pharmaceutical_Care/Publications/Posters/Medication_ Review/2011_Messerli_Poster_PMC_ESCP_A3.pdf. Accessed 30 Jan 2016. 10. Boeni F, Spinatsch E, Suter K, Hersberger K, Arnet I. Effect of drug reminder packaging on medication adherence: a systematic review revealing research gaps. Syst Rev. 2014;3(1):29. 11. Barnett N. The new medicine service and beyond: taking concordance to the next level. Pharm J. 2011;287(7681):653.
12. Allemann SS, van Mil JW, Botermann L, Berger K, Griese N, Hersberger KE. Pharmaceutical care: the PCNE definition 2013. Int J Clin Pharm. 2014;36(3):544–55. 13. Mehuys E, Dupond L, Petrovic M, Christiaens T, Van Bortel L, Adriaens E, et al. Medication management among home-dwelling older patients with chronic diseases: possible roles for community pharmacists. J Nutr Health Aging. 2012;16(8):721–6. 14. Reich O, Rosemann T, Rapold R, Blozik E, Senn O. Potentially inappropriate medication use in older patients in Swiss Managed Care Plans: prevalence, determinants and association with hospitalization. PLoS ONE. 2014;9(8):e105425. 15. Hersberger KE, Botomino A, Sarkar R, Tschudi P, Bucher HC, Briel M. Prescribed medications and pharmacy interventions for acute respiratory tract infections in Swiss primary care. J Clin Pharm Ther. 2009;34(4):387–95. 16. Glass BD, Haywood A, Llewelyn V, Mangan M. Compliance aids and medicine stability: new evidence of quality assurance. Curr Drug Saf. 2009;4(1):74–8. 17. Kwan JL, Lo L, Sampson M, Shojania KG. Medication reconciliation during transitions of care as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158(5 Pt 2):397–403. 18. Mulhem E, Lick D, Varughese J, Barton E, Ripley T, Haveman J. Adherence to medications after hospital discharge in the elderly. Int J Fam Med. 2013;2013:6. 19. Hersberger K, Boeni F, Arnet I. Dose-dispensing service as an intervention to improve adherence to polymedication. Expert Rev Clin Pharmacol. 2013;6:413–21.
REVIEW ARTICLE
Development of Clinical Pharmacy in Switzerland: Involvement of Community Pharmacists in Care for Older Patients Kurt E. Hersberger1 • Markus Messerli1
Springer International Publishing Switzerland 2016
Abstract The role of the community pharmacist in primary care has been undergoing change in Switzerland in parallel to international developments: it has become more clinically and patient oriented. Special services of community pharmacists to older patients taking long-term or multiple medications, discharged from hospitals or experiencing cognitive impairment or disability have been developed. These services require more clinical knowledge and skills from community pharmacists and are based on, for example, ‘simple or intermediate medication reviews’ focused primarily to improve medication adherence and rational drug use by a patient. Reflecting the new role of community pharmacies, this article describes the current services provided by community pharmacies in Switzerland, e.g., ‘polymedication check’, ‘weekly pill organizer’, and ‘services for chronic patients’, as well as new Swiss educational and reimbursement systems supporting development of these services. In the international context, involvement of community pharmacists in patient-oriented care is growing. This review summarizes positive and negative experiences from implementation of community pharmacy services in Switzerland and provides examples for the development of such services in other countries.
& Kurt E. Hersberger [email protected] 1
Pharmaceutical Care Research Group, Department of Pharmaceutical Sciences, University of Basel, Klingelbergstr. 50, 4056 Basel, Switzerland
Key Points For chronic patients new community pharmacistled services have been developed and implemented in Switzerland (e.g. medication review, weekly pill organizer filled by the pharmacy or structured triage algorithms for specific care situations). Clinical pharmacy knowledge and skills are essential also for community pharmacists when providing pharmaceutical care to ambulatory patients. The Swiss Association of Pharmacists strengthened the efforts in the development of clinical pharmacy services, mainly through own initiatives and sponsoring of four 50% professorships in Basel and Geneva.
1 Introduction The Swiss healthcare system is characterized by both liberalism and federalism (see Box 1). The environment in which the 1764 community pharmacies operate for eight million inhabitants is fairly competitive: dispensing physicians, mail order pharmacies, high proportion of about 30 % of chain pharmacies, no restriction to opening new pharmacies, and continuous pressure on pharmacists’ margins pose distinct problems for the development of clinical pharmacy services provided through community pharmacies. In this context, the Swiss Association of Pharmacists has adapted international developments and initiated an in-depth reform of the profession.
K. E. Hersberger, M. Messerli
Box 1 The Swiss healthcare system Each person living in Switzerland is obliged to purchase mandatory health insurance from an authorized insurer. They are free to choose their healthcare physician and have unlimited access to general praconers and specialists. There is no formal gatekeeping system in place. Almost half of the populaon (46 %) holds a special insurance policy where they receive premium reducons in exchange for agreeing to join one of the 90 exisng managed-care networks such as Health Maintenance Organisaons, family-doctor gatekeeping schemes, Independent Pracce Associaons, or Preferred Provider Organisaons. The naonal healthcare system is individually regulated by the cantons and 26 different systems have to be considered. Notably, in 16 cantons, physicians may dispense drugs directly to their paents (dispensing physicians). Ambulatory services are largely provided by physicians operang as independent/single-person pracces. In addion, ambulatory services are also provided by outpaent departments of public and private hospitals and by managed-care-style organisaons. Similarly, a liberal regulaon of medicines supply allows for dispensing physicians, pharmacy chains, mail order pharmacies, and supply of some over-the-counter drugs outside of a pharmacy [1].
In the early 1990s, pharmaceutical care was introduced in community pharmacy practice, and emphasis was given to providing patient-centered care and cognitive pharmaceutical services [2]. A postgraduate education program and obligatory continuous education were launched together with changes to pharmacists’ remuneration, which links payments to services delivered and not only to the volumes of medicines dispensed (see Table 1).
2 Initiatives by the Swiss Association of Pharmacists As the combination of rising multi-morbidities and health workforce shortages for medical professionals becomes more pronounced, especially with general practitioners
(GPs), pharmacists hold the potential to provide constructive support in medication management and the coordination of care. While efforts are made to re-orient pharmacy practice towards a focus on quality of care, policies allowing doctors to dispense drugs in some Swiss regions work against and create perverse competition in primary care and hamper coordination among networks of healthcare providers. Regardless of these barriers (or eventually induced by them), the Swiss Association of Pharmacists strengthened the efforts in the development of clinical pharmacy services, mainly through a quality-care program named QMSPharmacy (Quality Management System for Community Pharmacies), different campaigns (e.g., screening for cardiovascular risks, chronic obstructive pulmonary disorder, colorectal cancer, melanoma, microalbuminuria), the
Table 1 Services supporting rational and cost-effective drug use provided by Swiss community pharmacies: remuneration in Switzerland and according fees (examples) Pharmacy service
Description/activities
Fee (EUR) [1]
Delivery check
Each prescription: check of medication history for interactions and accumulation (including self-medication)
3.00
Drug check
Each dispensed item
4.00
• Check for: eventual possibility of repeat dispensing, dosage, limitations, interactions, risk factors, contraindications, misuse • According activities: patient counseling, eventual contact with prescriber, choice of optimized package size, immediate provision Generic substitution
Pharmacists have been allowed (and are officially invited) to substitute generic drugs for originals with the patient’s agreement and when the doctor does not oppose it
40 % of the difference to the original
Only at first delivery, a fee is available Emergency fee
To cover the extra charges of the pharmacist on emergency, night, and weekend duty, requested per patient and visit
16.00
Supervision of directly observed treatment
When a patient takes drugs in the pharmacy under the pharmacist’s supervision (e.g., opioids, disulfiram)
10.00
Adherence fee
For preparation of a weekly pill organizer/blister pack for an outpatient with a chronic condition and taking at least 3 different drugs
20.00/week
For patients on C4 prescribed drugs taken over C3 months
45.00
Polymedication check
If patient agrees, but independently from the prescriber
Development of Clinical Pharmacy in Switzerland
development of smoking cessation programs, and, recently, by a new telemedicine service called netCare (see Box 2). In addition, the association saw the need to change the basic education and to foster clinical training during the 5-year pharmacy curriculum (3-year Bachelor in Pharmacy Sciences/2-year Masters in Pharmacy). They became engaged in sponsoring 50 % professorships, two in Basel and two in Geneva. This funding, over a period of 5 years, has currently been translated into sustained installation of the four professorships in clinical pharmacy and pharmacy practice by the respective universities. The patient-oriented teaching was significantly improved and each of the four professorships showed impressive development of the research group with scientific output. Similarly, the introduction of ‘quality circles’ supported by the association provides an example of a collaboration to improve physician-prescribing behavior towards evidence-based policies. Currently, about 80 quality circles are active across Switzerland. They bring together five to eight physicians and pharmacists to develop collective evidence-based guidelines and to put these recommendations into practice. While it has been shown that they improve quality and efficiency, the effects on cost savings have been varied [3, 4]. While some insurers have already financially supported quality circles where they achieve savings, efforts to provide incentives for improved quality in prescribing and medication management are likely to become increasingly worthwhile for responding to changing health needs that are driven by an aging population and rising chronic disease [1].
3 Polymedication Check Since 2010, Swiss community pharmacies can offer a ‘polymedication check’ (PMC) to patients on four or more prescribed drugs taken over C3 months. Referring to the different types of medication reviews, defined by the Pharmaceutical Care Network Europe, the PMC is identified as an ‘intermediate’ medication review (see Box 3). Information is available from the medication history, which is mandatorily kept in Swiss community pharmacies, and from a structured patient interview. The check focuses on adherence problems, patients’ knowledge, and handling problems. Pharmacists are instructed to use open questions to detect pharmaceutical care issues and to decide on the need for intervention. However, they must prioritize the problems detected and document in a very simple way if the patient needs counseling (yes/no), has adherence problems (yes/no), if the pharmacist has to consult with the GP, refer the patient, or suggest any other recommendations or interventions. At the end of the interview, the patient signs the documentation form and the pharmacy can charge a fee of 45 Euros to the health insurer. Evaluations of the service showed that simplifications in therapy plans and improvement of knowledge provided by pharmacists are highly appreciated. Patients need wellfounded answers. An example is the frequent question on the best timing of medication intake. As polypharmacy has developed in each patient over a long period of time, the review of the intake schedule becomes essential and altering the timing of the intake may improve therapeutic outcomes. While some medicines need to be taken
Box 2 netCare: a new telemedicine service in Swiss pharmacies netCare allows paents to get a first structured triage based on decision trees for the most common diseases. The triage can result in (a) treatment by the pharmacist, (b) referral to a physician, or (c) asking the telemedicine doctor’s help by video from the pharmacy with eventual provision of a prescripon directly transmied to the pharmacy. The service comprises a follow-up aer 3 days to evaluate if the treatment is efficient. The project started in April 2012 with 200 pharmacies and a study will evaluate the efficiency, safety, and efficacy of the service [5].
Box 3 Types of medicaon reviews, defined by the Pharmaceucal Care Network Europe [6] Simple medicaon review (only Based on drug history, refill data one source of informaon) Intermediate medicaon review Type A: Based on drug history, refill data, AND paent interview (two sources of informaon) Type B: Based on drug history, refill data, AND clinical data (diagnoses, laboratory data) Advanced medicaon review Based on full informaon from drug history, paent interview, (three or more sources of AND clinical data informaon)
K. E. Hersberger, M. Messerli
separately (e.g., bisphosphonate, L-thyroxin), most longterm medication can be taken at the same time, preferably in the morning and avoiding doses to be taken at lunch. Thus, when performing medication use reviews, knowledge of disease and chronopharmacology is important. Pharmacists have to take note of the pharmacokinetic properties and the ‘forgiveness of drugs’ to optimize therapeutic coverage and to cope with risks of non-adherence. Skills in disease management are important and chronotherapy is now also an emerging concept [7]. Implementation of such cognitive services provided by a pharmacist is known to be very challenging [8]. The same is true for Swiss community pharmacies. Implementation of the PMC is low and after 3 years only about three checks per pharmacy per year were registered, with a large majority of pharmacies not offering this service. Focus group discussions revealed ‘‘no time’’, ‘‘not my responsibility, ‘‘patients do not understand the service’’, and ‘‘service already included in validation of prescription’’ as barriers to providing a PMC [9]. Pharmacists become highly motivated after first experiences, thus, ‘‘the first is the worst’’. In an ongoing randomized controlled trial (NCT01739816), we are observing 450 patients recruited from 70 study pharmacies. The primary outcome focuses on the improvement of adherence after the PMC (using the medication possession ratio and patients’ interviews). The second outcome is the number of unplanned consults with a physician or hospitalization. In addition, we evaluated various aspects of self-management. First results have proven the feasibility of this service and they reveal a wide range of pharmaceutical care issues to be addressed in such a counseling session.
4 Weekly Pill Organizer Through the PMC, pharmacists can evaluate a patient’s need for a weekly pill organizer (WPO). Either the pharmacy can provide a pill box to be filled by the patient or caregiver himself, or if the patient agrees and is taking at least three different medicines, the pharmacy can prepare a pill organizer/blister pack. This additional service is also remunerated by 20 Euros/week. Although evidence of the impact of dose reminder systems is still weak and our recent systematic review revealed important research gaps [10], we consider this service very important. Currently, most WPOs filled in by a pharmacy are dispensed upon a prescription of the physician. Because about ten patients per pharmacy receive a drug reminder system regularly from their pharmacy, pharmacists seem to be much more open to such a service than to the more challenging PMC. However, preparation of a WPO requires repeated
Fig. 1 Workflow dose-dispensing service [19]
medication reviews. Figure 1 shows the workflow: first, at initiation to screen for non-adherence problems; second, to find the adequate solution(s) for the patient and in case of a drug reminder system being the agreed intervention, the best configuration of a patient’s regimen into the available (in general, four) intake times. Very shortly after the initiation of the service, a follow-up is needed, which can be done by phone. Later, either in a 6-month sequence or at each significant change of the therapy (namely after hospital discharge), a next medication review becomes due.
5 Services for Chronic Patients through Swiss Community Pharmacies In general, patients visit a pharmacy without advance announcement and the pharmacist provides counseling in an ad hoc situation. The pharmacist reacts to the patient spontaneously and counsels at the counter, without any further preparation. This setting does not provide privacy or the possibility to switch to a counseling room. Figure 2 summarises the different services provided by community pharmacies in a patient’s journey: the patient attends the pharmacy the first time with a new prescription for longterm medication and receives adequate instructions (A). Currently, there is no special service implemented, such as the new medicines service in the UK [11]. The new medicine is commonly evaluated by the GP after 1 month and at that time he/she can prescribe a repeat prescription for up to 12 months (B). Thereafter, the patient will show up regularly to receive a refill in the pharmacy (D) or to request over-the-counter medicines to treat minor illness
Development of Clinical Pharmacy in Switzerland Fig. 2 Journey of a chronic patient according to ad hoc or planned activities of a community pharmacist. ADE adverse drug event, GP general practitioner, H hospital, OTC over-the-counter medicine
(C), or with a question (E) concerning a manifest or potential drug-related problem. The patient will see his/her GP for a renewal of the repeat prescription or for an eventual change (F) of the prior treatment plan only after 6 months or 1 year. All these situations might prompt a deepened evaluation of the patient situation. Hereby, the ad hoc counseling evolves to structured pharmaceutical care services. They are mostly planned and can comprise an assessment of patient outcomes (V), a medication review (W) triggered by the questions of the patient, or a telephone interview as a follow-up of the therapy change (X). With respect to seamless care, reconciliation of therapies (Y) around a hospital stay represents another very relevant service and for disabled patients even a home medication review after discharge (Z) might be adequate. Currently, Swiss community pharmacists could, in all situations C–G, perform a PMC and receive remuneration. Therapy monitoring (V) by the pharmacist is not systematically foreseen. Still, the measurements of blood pressure, biomarkers for diabetes mellitus patients, or even lipid values are frequently offered. In general, these services are paid by the patient. However, accredited pharmacies following regular quality controls may perform prescribed testing by use of capillary blood and receive the standard payment for laboratory testing. There exist other services with distinct responsibilities, which are not (yet) covered by a specific fee. For example, when a refill prescription is expired, the pharmacist is also allowed to dispense a long-term medicine in advance to avoid interruption of the therapy (e.g., dispensing of phenytoin for a home resident whose neurologist is on holidays). In well-defined situations, even dispensing
without a prescription is permitted, according to a guideline that clearly specifies good practice with adequate documentation. Examples are replacement of expired medicine, salbutamol inhaler in the case of an asthma attack, and glyceryl trinitrate for angina.
6 Discussion Targeting individuals and not a population or society as a whole is a key concept of pharmaceutical care that can be viewed as an individualized service of pharmacists delivered to a distinct patient. Very recently, the Pharmaceutical Care Network Europe redefined the term pharmaceutical care as ‘‘the pharmacist’s contribution to the care of individuals in order to optimize medicines use and improve health outcomes’’ [12]. These services contain various contributions of pharmacists in patient-oriented care and the provision of medication reviews by pharmacists on different levels: simple, intermediate, and clinical. They are not subject to a specific setting: pharmacists possessing clinical knowledge and skills can provide pharmaceutical care when working in community pharmacies, within or for nursing homes or in hospitals. ‘Pharmaceutical care’ thus represents a broad concept of the involvement of various pharmacists in the optimization of patients´ pharmacotherapy in different settings of care. In community pharmacies, multiple-care issues can be addressed and relevant interventions are feasible. Mehuys [13] listed possible roles for community pharmacists when dealing with older patients with chronic diseases. In addition to drug–drug interactions, non-adherence, and
K. E. Hersberger, M. Messerli
deficient knowledge of patients, he also listed practical problems with drug taking such as difficulties with vision 32 %, blister opening 12.1 %, tablet swallowing 14.8 %, tablet splitting 29.7 %, and distinguishing between different drug packages 23.4 %. All of these drug-related problems are often supposed to be minor, but they might significantly impede the outcomes of a therapy. Potentially inappropriate medication (PIM) use in the older population is very prevalent in Switzerland as well. A recent study [14] revealed lower prevalence rates of PIM use in older managed-care patients compared with patients outside a managed-care plan (18.6 vs. 21.1 %). Hence, irrespective of belonging to a managed-care health plan, there is large room for improvement in PIM use. In Switzerland, repeat prescribing for a maximum of 12 months is allowed and such prescriptions currently constitute nearly 75 % of all items dispensed [15]. Hence, community pharmacies assume very responsible roles in the care of chronic patients. The recently introduced PMC is therefore a very important activity. More research, especially on the implementation and introduction of new remunerated services (such as a specific medication review after hospital discharge, telephone follow-up after changes of the therapy plan) is much desired. In addition, interprofessional collaboration should be fostered and obvious barriers such as drug-dispensing physicians need to be restricted. Because Swiss pharmacists are allowed to start a drug reminder system after such a PMC, delivery of a dosedispensing service poses multiple issues that are typically part of clinical pharmacy services. Often, the therapy plan needs to fit with the predefined options of a pill box and not all medicines can be dispensed because of stability problems [16]. Transitions of care imply changes in the level, location, or providers of care. Community pharmacies are very often the first of all healthcare providers involved after hospital discharge. Reconciliation of therapies is much more than a puzzle game! When reconciliation is seen as the starting point for a structured pharmaceutical care service and is bundled with interventions aimed at improving care transitions post-discharge, healthcare use may be reduced [17]. Mulhem observed 24–48 h after discharge non-adherence in 20 % of the patients [18]. Thus, a close follow-up is important and a simple telephone follow-up could easily be performed. However, when counseling potentially nonadherent patients, challenging problems could arise. Examples are action to be taken when one or two doses are missed, how to restart therapy after a drug holiday, and information on the risk of rebound effects when medication is immediately stopped. The basics of clinical pharmacy knowledge and skills are essential also for community pharmacists to address all
these issues, and specific knowledge is needed to perform clinical services for an individual patient. In fact, community pharmacists providing cognitive services (e.g., motivational interviewing) are in need of much more training in clinical pharmacy issues related to patient care in this specific population to become adequately skilled. However, patient outcomes have yet to be shown to be improved by the new services to be sustainably integrated into the Swiss primary care setting. Undergraduate teaching on the basics of patient care must be followed by postgraduate training. Currently, different university-based courses are in preparation (e.g., Certificate of Advanced Studies in Clinical and/or Hospital Pharmacy in Geneva and Basel).
7 Conclusion The involvement of community pharmacists in patient care in Switzerland is rising. The PMC in the format of an intermediate medication review is a promising new service. We need to foster patient-oriented education and training and to closer link hospital and community pharmacists through collaborative initiatives for postgraduate education. Strengthening of research on a local as well as an international level is essential to develop, implement, and continuously improve clinically oriented services provided also by community pharmacists. Acknowledgments The authors thank Emily Schultz from the Sustainability Research Group at the University of Basel for helpful comments in the preparation of this manuscript. This article is based on a presentation at the 42nd European Society of Clinical Pharmacy Symposium on the Implementation of Clinical Pharmacy Practice: Research, Education and Management, held in Prague, Czech Republic, October 2013. Compliance with ethical standards Conflicts of interest
The authors have no conflicts of interest.
Funding No sources of funding were received for the preparation of this article.
References 1. OECD reviews of health systems: Switzerland 2011 [cited 2014 03.03.2015] (Ref: OECD/WHO (2011). Geneva: OECD Publishing; 2011. doi:10.1787/9789264120914-en). Accessed 2016 Jan 30. 2. Sa´ez-Benito L, Fernandez-Llimos F, Feletto E, Gastelurrutia MA, Martinez-Martinez F, Benrimoj SI. Evidence of the clinical effectiveness of cognitive pharmaceutical services for aged patients. Age Ageing. 2013;42(4):442–9. 3. Guignard E, Bugnon O. Pharmaceutical care in community pharmacies: practice and research in Switzerland. Ann Pharmacother. 2006;40(3):512–7.
Development of Clinical Pharmacy in Switzerland 4. Niquille A, Ruggli M, Buchmann M, Jordan D, Bugnon O. The nine-year sustained cost-containment impact of Swiss pilot physicians-pharmacists quality circles. Ann Pharmacother. 2010;44(4):650–7. 5. Ruggli M, Erni P. netCare: a new telemedicine service in Swiss pharmacies 2012 [03.03.15]. Available from: http://www.pcne. org/conferences/wc2013/Abstracts/4-Ruggli.pdf. Accessed 2016 Jan 30. 6. Griese-Mammen N, Leikola S. Sliema, Malta: Pharmaceutical Care Network Europe; 2014. Available from: http://www.pcne. org/upload/files/28_Malta_MR_report.pdf. Accessed 2016 Jan 30. 7. Kaur G, Phillips C, Wong K, Saini B. Timing is important in medication administration: a timely review of chronotherapy research. Int J Clin Pharm. 2013;35(3):344–58. 8. Houle SKD, Grindrod KA, Chatterley T, Tsuyuki RT. Paying pharmacists for patient care: a systematic review of remunerated pharmacy clinical care services. Can Pharm J. 2014;147(4):209–32. 9. Messerli M. Polymedication-check: first experiences with a new reimbursed cognitive service 2011 [poster presentation]. Available from: https://pharma.unibas.ch/fileadmin/pharma/redaktion/ groups/Pharmaceutical_Care/Publications/Posters/Medication_ Review/2011_Messerli_Poster_PMC_ESCP_A3.pdf. Accessed 30 Jan 2016. 10. Boeni F, Spinatsch E, Suter K, Hersberger K, Arnet I. Effect of drug reminder packaging on medication adherence: a systematic review revealing research gaps. Syst Rev. 2014;3(1):29. 11. Barnett N. The new medicine service and beyond: taking concordance to the next level. Pharm J. 2011;287(7681):653.
12. Allemann SS, van Mil JW, Botermann L, Berger K, Griese N, Hersberger KE. Pharmaceutical care: the PCNE definition 2013. Int J Clin Pharm. 2014;36(3):544–55. 13. Mehuys E, Dupond L, Petrovic M, Christiaens T, Van Bortel L, Adriaens E, et al. Medication management among home-dwelling older patients with chronic diseases: possible roles for community pharmacists. J Nutr Health Aging. 2012;16(8):721–6. 14. Reich O, Rosemann T, Rapold R, Blozik E, Senn O. Potentially inappropriate medication use in older patients in Swiss Managed Care Plans: prevalence, determinants and association with hospitalization. PLoS ONE. 2014;9(8):e105425. 15. Hersberger KE, Botomino A, Sarkar R, Tschudi P, Bucher HC, Briel M. Prescribed medications and pharmacy interventions for acute respiratory tract infections in Swiss primary care. J Clin Pharm Ther. 2009;34(4):387–95. 16. Glass BD, Haywood A, Llewelyn V, Mangan M. Compliance aids and medicine stability: new evidence of quality assurance. Curr Drug Saf. 2009;4(1):74–8. 17. Kwan JL, Lo L, Sampson M, Shojania KG. Medication reconciliation during transitions of care as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158(5 Pt 2):397–403. 18. Mulhem E, Lick D, Varughese J, Barton E, Ripley T, Haveman J. Adherence to medications after hospital discharge in the elderly. Int J Fam Med. 2013;2013:6. 19. Hersberger K, Boeni F, Arnet I. Dose-dispensing service as an intervention to improve adherence to polymedication. Expert Rev Clin Pharmacol. 2013;6:413–21.
