Pharmaceutical care in Europe
Latest developments
Dr. J.W.Foppe van Mil
Community Pharmacist
Professional Secretary PCNE
Question 1
• How far are we in implementing
pharmaceutical care by pharmacists in
Europe? What are the issues?
Question 2
• Have we managed to prove in Europe that
pharmaceutical care by pharmacist
improves the patients’ outcomes (ECHO
– Clinical outcomes
– Economical outcomes
– Humanistic outcomes
• quality of life: = the outcome that matters for the
• satisfaction
• How to assess the status of
pharmaceutical care
• Latest literature
• Status disease-wise
• What still needs to be done
• Conclusion
How to assess the status of
pharmaceutical care
• Literature review
• Talk to colleagues, be part of PCNE,
ESCP and Europharm
• Listen to many speakers at conferences
• Ask questions……
• Do we then get the answers?
Challenges especially in Europe
• Varying health care systems
• Different roles of pharmacists
• Varying definitions of what constitutes pharmaceutical
• Different terminologies
• Inaccessible languages
– Example: Farmacia hospitalaria : órgano oficial de expresión
científica de la Sociedad Española de Farmacia Hospitalaria in
• Many national and even local pharmacy practice
publications, that are not in Medline or any other
Recent Issues
Implementation & barriers
Several papers on ethics and legislation
Role of pharmacists vs staff
Relationship with other health-care
professionals and with the patient (UK)
• Adapting and working with instruments
e.g. Beers Criteria for medication reviews
Beers criteria, developments
• Beers criteria are an instrument to conduct a
comprehensive medication review in the elderly, first
published in the US in 1991
• Expert panel identified 19 drugs that should generally be
avoided and 11 doses, frequencies, or durations of use
of specific drugs that generally should not be exceeded.
• Example: certain medicines should not be prescribed to
the elderly e.g. short acting benzodiazepines, long acting
barbiturates etc.
• Instrument not appropriate for use in European countries
because of the differences in national drug formularies
and prescribing practices and attitudes.
• Effectiveness of instrument depends on its setting: must
be adapted to time, population, national drug selections.
Beers criteria, adaptations
• Update by Beers et al in 1997 (for US)
• Update by Flick et al in 2003 (for US)
• 2006 Language/culture and medicine adaptation
for Portugal (de Olivieira) and France (Larochet)
• 2007 Language/culture and medicine
adaptations being done for Germany, Poland
and the Netherlands
• But …. adaptations make international
comparisons more difficult.
van Mil JWF. Atención Farmacéutica en Farmacia Comunitaria en
Europa, retos y barreras [Pharmaceutical Care in Community
Pharmacy in Europe, challenges and barriers]. Pharm Care Esp
Berenguer B, La Casa C, de la Matta MJ, Martin-Calero MJ.
Pharmaceutical care: past, present and future. Curr Pharm Des
Martin-Calero MJ, Machuca M, Murillo MD, Cansino J,
Gastelurrutia MA, Faus MJ. Structural process and
implementation programs of pharmaceutical care in different
countries. Curr Pharm Des 2004;10(31):3969-3985
van Mil JWF, Schulz M. A review of Pharmaceutical Care in
Community Pharmacy in Europe. Harvard Health Policy Review
2006;7 (1):155-168
Annals series
• Series of articles on Community Pharmacy
in the world in Annals of Pharmacotherapy
• Ongoing series coordinated by people in
US, Europe and Australia
• Publications from Eastern Europe and
Asia still lacking
Focus of Annals publications(1)
Asthma study + implementation
Improving medication in the elderly
Appropriateness of medication
Drug related problems
Counselling/Pseudo customers
Self-care and OTC
Implementation research (with
Spain and Portugal)
Focus of Annals publications(2)
Asthma, Diabetes
The Family Pharmacy project
Pseudo customer/ counselling
Local Quality circles (FTOs in NL)
Health promotion activities
(Diabetes, smoking cessation)
Self care & referral
PhC in the elderly and their DRPs
Focus of Annals publications(3)
Medicine use reviews
Smoking cessation support
Methadone programs
Pharmacist prescribing
Methadone & needle exchange
Generic disease management
Activities in the Netherlands
Individualised pharmaceutical care
1. Medication surveillance and coaching.
2. Medication analysis based on selections with
3. Disease oriented projects
4. Special instructions at therapy initiation
5. Home care and OTC counselling
Supporting activities
• Seamless care data transfer
• Pharmacotherapy discussions with physicians
• Germany: Community pharmacy-based pharmaceutical care for
asthma patients: Positive impact on humanistic and clinical
outcomes. Mangiapane et al. Ann.Pharmacother. (2005).
• Belgium: Medication use and disease control of asthmatic patients
in Flanders: a cross-sectional community pharmacy study: No
intervention yet, test of Instrument. Mehuys et al. Respir.Med
• Review: More favourable PC outcomes were associated with use of
all elements of PC, independent pharmacies, pharmacist
certification, a detailed PC protocol, targeting patients with
uncontrolled asthma, and a practice system facilitating innovation
PC. McLean et al. Ann Pharmacother (2005)
• Other positive data from Denmark (Herborg), Spain (Andrès), Malta
(Cordina), N. Ireland(Cordina) and Netherlands (van Mil, StuurmanBieze)
• Review: Sensitivity of Patient Outcomes to Pharmacist
Interventions. Part I: Systematic Review and Meta-Analysis in
Diabetes Management. General conclusion: HbA1C levels
are sensitive to pharmacist interventions. Machado et al.
Ann.Pharmacother. (2007, not only Europe).
• Switzerland: Pharmaceutical care model for patients with
type 2 diabetes: integration of the community pharmacist into
the diabetes team-a pilot study: Reduction in HbA1c and
cholesterol values. Wermeille et al. Pharm.World Sci (2004).
• Belgium: Medication use and disease management of type 2
diabetic flemish patients: Pharmacist should take a role.
Mehuys et al. Pharm World Sci (2007)
• Norway: Diabetes care in pharmacy. 30% Of pharmacist
involved in diabetes care. Kjome et al. PWS (2007 on-line
• Turkey: Effect of pharmacist-led patient
education on adherence to tuberculosis
treatment: Improved adherence. Clark et
al. Am.J Health Syst.Pharm. ( 2007)
• Spain: Pharmaceutical care in hiperlipemic drug
patients. Decrease in the mean values of total
cholesterol and triglycerides. Cardo Prats et al.
Pharm Care Esp (2001).
• Germany: Pharmaceutical care in patients with
disturbed lipaemic patterns: Improved lipid profiles,
improved compliance. Birnbaum et al. Pharm.Ztg.
• Belgium: Effect of intervention through a pharmaceutical
care program on patient adherence with prescribed
once-daily atorvastatin: improved compliance and
persistence. Vrijens et al. Pharmacoepidemiol.Drug Saf
15 (2):115-121, 2006.
Parkinsons’ disease
• UK: Pilot in PhC in community pharmacy
of Parkinson patients: Increased
compliance. Minors et al. Pharm J (2007):
• Scotland: Effect of educational intervention
on medication timing in Parkinson's
disease: a randomized controlled trial:
Improved timing adherence. Grosset KA et
al. BMC Neurol. (2007).
• Denmark: Pharmaceutical Care in borderline Migraine.
No clear impact. Soendergaard et al. Scand J Prom
Health Care (2006).
Congestive Heart Failure (CHF)
• Spain: Post discharge Pharmaceutical care in heart
failure: Reductions in readmissions and hospital
stay. Lopez Cabezas et al. Farm.Hosp (2006).
• UK: Medicines management in Coronary Heart Failure.
But: no positive impact. Holland et al, (BMJ 2007).
Over The Counter
• In the past there have been many studies in the
past in the field of Over The Counter medication.
• These studies show a positive impact of
counselling on behaviour and satisfaction
• In many countries OTC counselling has been
implemented in practice, and structured
• But…… Counselling is not pharmaceutical care!
and there has been no follow-up
• Impact of PhC on outcomes in OTC medication
remains an important field for study!
Drug Use Review (1)
• Netherlands: FTOs: Latest report of DGV indicates 808
pharmacotherapy discussion groups in NL, of which more than
50% function optimally. DGV report 2007
• UK: Home-based medication review in a high risk elderly population
in primary care--the POLYMED randomised controlled trial: Had
only impact on number of medicines (economics?). Lenaghan et
al. Age Ageing 2007.
• UK: Review in chain pharmacies. Study from University of
Nottingham to be published.
• Poland: Polypharmacy and potential inappropriateness of
pharmacological treatment among community-dwelling elderly
patients: it is a frequent problem in Poland, and a project has
been started. Rajska-Neumann et al. Arch Gerontol.Geriatr. (Suppl
Drug Use Review (2)
• France: Implementation of a Canadian Pharmaceutical
Care model in a French paediatric department. Many
DRPs detected and solved. Proth Labarthe et al. Arch
Pediatr (2007).
• N. Ireland: Preventing hospital readmissions by
medicines management: Rate of, and time to
readmission decreased. Scullin et al. J Eval Clin Pract
• Belgium: Improving appropriateness of prescribing in
elderly people admitted and discharged in hospital, pilot.
Successful: improved appropriateness. Spinewine et
al. Ann Pharmacother (2006) J Am Geriatr Soc (2007).
Drug Use Review (3)
Nursing homes
• UK: Pilot of transfer Fleetwood model for Drug Use
Evaluations in nursing homes from the USA. Barrier is
seamless access to medical data. Huges C et al.
Pharm World Sci (2007)
• Netherlands: A study of medication reviews to identify
drug-related problems of polypharmacy patients in the
Dutch nursing home setting: 3,5 problems per patient
found, 1.7 problems solved at follow up. Finkers et al.
J Clin Pharm Ther (2007).
• Non-significant findings are usually not reported.
• In case of pharmacist interventions, however,
non-significant findings are sometimes reported
in especially medical journals (sic!)
• Magnitude of the effects of pharmaceutical care
interventions also depends on the current state
of healthcare: impact of a diabetes intervention
will potentially be largest in countries where the
diabetes patients are badly regulated.
Conclusion (1)
• Disease oriented pharmaceutical care does
have a proven effect on intermediate outcomes
like adherence and (of course…) patient
• Comprehensive medication review has an
impact on the appropriateness of the
pharmacotherapy, but real effects on the ECHO
outcomes have not yet been firmly established.
• More insight into the real implementation of
pharmaceutical care in Europe is urgently
• How to assess the status of
pharmaceutical care
• Latest literature
• Status disease-wise
• Status of the implementation
• What still needs to be done
• My personal impression is that pharmacists, and
especially their organisations in most countries
are still too busy with M&Ms (management and
• Pharmacists and their associations should
realise that the value of the profession to society
can not be measured in Euros earned, but in the
impact they have on the outcomes that matter to
the patient.
• The question if pharmacists must provide
pharmaceutical care lies behind us: yes we
must; please start

Presentation Oviedo - PHARMACEUTICAL CARE