Preferences for innovations in healthcare delivery models in the Swiss elderly population: a latent class, choice modelling study.

BACKGROUND: With the increasing number of people affected by multiple chronic conditions, it is essential for public-health professionals to promote strategies addressing patient needs for coordinated care. We aim to explore preference heterogeneity for better-coordinated care delivery models in Swiss older adults, and identify profiles of individuals more open to healthcare reforms. METHODS: A DCE (discrete choice experiment) survey was developed online and on paper for the Swiss adults aged 50+, following best practice. To elicit preferences, we estimated a latent class model allowing grouping individuals with similar preferences into distinct classes, and examined what background characteristics contributed to specific class membership. RESULTS: The optimal model identified three classes with different openness to reforms. Class 1 (49%) members were concerned with premium increases and were in favour of integrated care structures with care managed by interprofessional teams. Individuals in class 2 (19%) were younger, open to reforms, and expressed the needs for radical changes within the Swiss healthcare system. Class 3 respondents (32%) were strongly reluctant to changes. CONCLUSIONS: Our study goes beyond average preferences and identifies three distinct population profiles, a majority open to reforms on specific aspects of care delivery, a smallest group in favour radical changes, and a third strongly against changes. Therefore, tailored approaches around healthcare reforms are needed, e.g. explaining the role of interprofessional teams in coordinating care, electronic health records and insurance premium variation.

Preferences of older adults for healthcare models designed to improve care coordination: Evidence from Western Switzerland.

Implementing innovations in care delivery in Switzerland is challenging due to the fragmented nature of the system and the specificities of the political process (i.e., direct democracy, decentralized decision-making). In this context, it is particularly important to account for population preferences when designing policies. We designed a discrete choice experiment to study population preferences for coordination-improving care models. Specifically, we assessed the relative importance of model characteristics (i.e., insurance premium, presence of care coordinator, access to specialists, use of EMR, cost-sharing for chronic patients, incentives for informal care), and predicted uptake under different policy scenarios. We accounted for heterogeneity in preferences for the status quo option using an error component logit model. Respondents attached the highest importance to the price attribute (i.e. insurance premium) (0.31, CI: 0.27- 0.36) and to the presence of a care coordinator (0.27, CI: 0.23 - 0.31). Policy scenarios showed for instance that gatekeeping would be preferred to free access to specialists if the model includes a GP or an interprofessional team as a care coordinator. Although attachment to the status quo is high in the studied population, there are potential ways to improve acceptance of alternative care models by implementation of positively valued innovations.

Building Interprofessional Collaborative Practices Through a Support Program for Patients With Type 2 Diabetes in Primary Care.

INTRODUCTION: The building of interprofessional collaborative practices throughout the implementation process of a patient support program (Siscare) in primary care for patients with type 2 diabetes was assessed. Siscare included regular patient-pharmacist motivational-based interviews; medication adherence, patient-reported, and clinical outcomes monitoring; and physician-pharmacist interactions. METHOD: This investigation was a prospective, multicenter, observational, mixed-methods cohort study. Interprofessionality was operationalized through four progressive levels of interrelationship practices between the health care professionals. The target number of patients per pharmacy was 10 among 20 pharmacies. RESULTS: The project started with the recognition of Siscare by stakeholders, the creation of an interprofessional steering committee, and the adoption of Siscare by 41 pharmacies among 47 pharmacies in April 2016. Nineteen pharmacies presented Siscare at 43 meetings attended by 115 physicians. Twenty-seven pharmacies included 212 patients; however, no physician prescribed Siscare. Collaboration primarily occurred through the unidirectional transmission of information from the pharmacist to the physician (level 1: 70% of pharmacists transmitted interview reports to physicians), bidirectional exchange of information sometimes occurred (level 2: 42% received physician responses), and concerted measures of treatment objectives took place occasionally (level 3). Twenty-nine of 33 physicians surveyed were in favor of this collaboration. DISCUSSION: Despite multiple implementation strategies, physician resistance and lack of motivation to participate exists, but Siscare was well received by pharmacists, patients, and physicians. Barriers to collaborative practice (financial and IT) need to be further explored. Interprofessional collaboration is a clear need to improve type 2 diabetes adherence and outcomes.

Effectiveness of an Interprofessional Program (Siscare) for Supporting Patients With Type 2 Diabetes.

Objective: To assess the effectiveness of an interprofessional support program (Siscare) that includes motivational interviews (patient-pharmacist), electronic monitoring (EM) of medications, patient-reported and clinical outcomes monitoring, and interactions with physicians for patients with type 2 diabetes in French-speaking Switzerland. Methods: This was a prospective, multicenter, observational cohort study using a hybrid implementation-effectiveness design. Individual daily adherence to at least one oral antidiabetic medication was measured by EM. A global adherence score was estimated by the product of a model-estimated implementation and a nonparametric estimate of persistence over time. Clinical outcomes (A1C, blood glucose, BMI, blood pressure, heart rate, and cholesterol levels) and quality of life (QoL) were analyzed over time using linear mixed-effect models. Results: A total of 212 patients were included from 27 pharmacies; 120 patients (57%) were followed up for at least 15 months. In total, 140 patients (66%) were male, the mean age was 64 ± 11 years, and the mean number of chronic medications per patient at baseline was 5 ± 3. Of 178 patients who used EM, 95% (95% CI 92-99%) remained persistent at the end of the follow-up period. The percentage of persistent patients taking their medications appropriately (implementation) was stable during follow-up and was estimated to be 90% (95% CI 87-92%) at baseline and 88% (95% CI 84-91%) at month 15. At baseline, the mean A1C and BMI were 7.5% and 31 kg/m2, respectively, which decreased by 0.5% (P = 0.012) and 0.6 kg/m2 (P = 0.017), respectively, after 15 months. QoL remained stable during follow-up. Conclusion: The program supports medication adherence and improves clinical outcomes, illustrating the overall preventive effect of coordinated care.

Association between continuity of care (COC), healthcare use and costs: what can we learn from claims data? A rapid review.

OBJECTIVE: To describe how longitudinal continuity of care (COC) is measured using claims-based data and to review its association with healthcare use and costs. RESEARCH DESIGN: Rapid review of the literature. METHODS: We searched Medline (PubMed), EMBASE and Cochrane Central, manually checked the references of included studies, and hand-searched websites for potentially additional eligible studies. RESULTS: We included 46 studies conducted in North America, East Asia and Europe, which used 14 COC indicators. Most reported studies (39/46) showed that higher COC was associated with lower healthcare use and costs. Most studies (37/46) adjusted for possible time bias and discussed causality between the outcomes and COC, or at least acknowledged the lack of it as a limitation. CONCLUSIONS: Whereas a wide range of indicators is used to measure COC in claims-based data, associations between COC and healthcare use and costs were consistent, showing lower healthcare use and costs with higher COC. Results were observed in various population groups from multiple countries and settings. Further research is needed to make stronger causal claims.

Exploring Patient Multimorbidity and Complexity Using Health Insurance Claims Data: A Cluster Analysis Approach.

BACKGROUND: Although the trend of progressing morbidity is widely recognized, there are numerous challenges when studying multimorbidity and patient complexity. For multimorbid or complex patients, prone to fragmented care and high health care use, novel estimation approaches need to be developed. OBJECTIVE: This study aims to investigate the patient multimorbidity and complexity of Swiss residents aged ≥50 years using clustering methodology in claims data. METHODS: We adopted a clustering methodology based on random forests and used 34 pharmacy-based cost groups as the only input feature for the procedure. To detect clusters, we applied hierarchical density-based spatial clustering of applications with noise. The reasonable hyperparameters were chosen based on various metrics embedded in the algorithms (out-of-bag misclassification error, normalized stress, and cluster persistence) and the clinical relevance of the obtained clusters. RESULTS: Based on cluster analysis output for 18,732 individuals, we identified an outlier group and 7 clusters: individuals without diseases, patients with only hypertension-related diseases, patients with only mental diseases, complex high-cost high-need patients, slightly complex patients with inexpensive low-severity pharmacy-based cost groups, patients with 1 costly disease, and older high-risk patients. CONCLUSIONS: Our study demonstrated that cluster analysis based on pharmacy-based cost group information from claims-based data is feasible and highlights clinically relevant clusters. Such an approach allows expanding the understanding of multimorbidity beyond simple disease counts and can identify the population profiles with increased health care use and costs. This study may foster the development of integrated and coordinated care, which is high on the agenda in policy making, care planning, and delivery.

Continuity of care and multimorbidity in the 50+ Swiss population: An analysis of claims data.

Objective: To assess the relationship between continuity of care (COC) and multimorbidity in the older general population in Switzerland, accounting for relevant determinants of COC, and to apply various expressions of multimorbidity derived from claims data. Methods: We used data on 240'000 insured individuals aged 50+ for the period 2015-2018, received from one of the largest Swiss health insurance company. We calculated Bice-Boxerman index based on all doctor visits (overall COC) and visits to the general practitioners (COC GP). We analyzed the relationship between COC and multimorbidity using generalized linear and probit models. To express multimorbidity, we applied three approaches based on pharmacy-cost groups (PCGs) assigned to an individual. First, we used simple PCG counts. Second, we expressed multimorbidity via clinically relevant disease groups derived from PCGs. Finally, a data-driven approach allowed defining distinct clusters representing different patient complexities. Results: The association between overall COC and multimorbidity expressed in PCG counts was modest: COC among individuals with 3+ PCGs was 2 percentage points higher than COC among individuals with 0 PCGs. The approach of clinically relevant disease groups showed larger variation in COC and its association with multimorbidity. The data-driven approach showed that most complex ("high-cost high-need") individuals tended to have higher overall COC. Additionally, 70% of the sample visited exclusively one general practitioner (COC GP = 1.0). Other important factors associated with COC in the Swiss context were insurance model with gatekeeping, level of deductibles, and region of residence. Conclusions: Multimorbid patients require regular medical attention often involving multiple healthcare providers, which can lead to varying COC, depending on types of doctors seen and specific condition of the patient. Insurance models with gatekeeping may facilitate COC, prompting developments of better-designed models of care. This represents important implications for policymakers, health insurance representatives, medical professionals and hospital managers.

Patient and Public Preferences for Coordinated Care in Switzerland: Development of a Discrete Choice Experiment.

OBJECTIVE: Our objective was to develop and test a discrete choice experiment (DCE) eliciting public and patient preferences for better-coordinated care in Switzerland. METHODS: We applied a multistage mixed-methods procedure using qualitative and quantitative approaches. First, to identify attributes, we performed a review of the DCE literature in healthcare with a focus on chronic care. Next, attribute selection involved stakeholders (N = 7) from various healthcare sectors to select the most relevant and actionable attributes, followed by three organized focus groups involving the general public and patients (N = 21) to verify the selection and the clarity of the DCE tasks and explanations. Finally, we conducted an online pilot in the target population to test the survey and obtain priors for a final six tested attributes to refine the final design of the experiment. RESULTS: After identifying an initial 33 attributes, a final list of six attributes was selected following stakeholder involvement and the three focus groups involving the target population. At the online pilot-testing stage with 301 participants, the majority of respondents found the DCE choice tasks socially relevant for Switzerland but challenging. The quality of the answers was relatively high. Most attributes had signs matching those in the literature and focus group discussions. CONCLUSION: This article will be useful to researchers designing DCEs from a broad health policy perspective. The multistage approach involving a range of stakeholders was essential for the development of a DCE that is relevant for policy makers and well-accepted by the general public and patients.

Continuity of care of Swiss residents aged 50+: a longitudinal study using claims data.

Background: Continuity of care (COC) should be measured for healthcare quality monitoring and evaluation and is a key process indicator for integrated care. Measurement of COC using routinely collected data is widespread, but there is no consensus on which indicator to use and the relevant time horizon to apply. Information about COC is especially warranted in highly fragmented healthcare systems, such as in Switzerland. Our study aimed to compare COC measures in Swiss residents aged 50+ obtained with various indices and time horizons. Methods: Using insurance claims data, we computed and compared several commonly used visit-based Continuity of Care Indices (COCIs): Bice-Boxerman Index, Usual Provider of Care, Herfindahl-Hirschman Index, Modified, Modified Continuity Index and Modified Continuity Index, based on all doctor visits and on primary care (PC) visits only. Indices were computed over short (1 year) and medium (4 years) terms. Results: The mean indices based on all visits varied between 0.51 and 0.77, while PC indices presented less variation with a median of 1.00 for all but one index. Indices focusing on a variety of individual providers decreased with time horizon, while indices focusing on the overall number of visits and providers showed the opposite trend. These findings suggest fundamental differences in the interpretation of COCIs. Conclusions: Broad COC appeared moderately low in Switzerland, although comparable to other countries, and PC COC was close to one. The choice of indices and time horizon influenced their interpretation. Understanding these differences is key to select the appropriate index for the monitoring of COC.

Implementation Evaluation of an Interprofessional Programme (Siscare) for Supporting Patients with Type 2 Diabetes in a primary care setting.

BACKGROUND: In 2016, the Swiss government decided to back the implementation of an interprofessional patient support programme to redefine and extent the pharmacist's role in primary care. The programme, called Siscare, includes regular motivational interviews by pharmacists; medication adherence, patient-reported, and clinical outcomes monitoring; and pharmacist-physician interactions. OBJECTIVE: To assess, from a pharmacy team's perspective, the implementation of Siscare for patients with type 2 diabetes taking at least one oral antidiabetic treatment, followed for 15 months, in a primary care setting of the French-speaking part of Switzerland. METHODS: This prospective, multicentre, observational, cohort study used a hybrid implementation-effectiveness design and the Framework for the Implementation of Services in Pharmacy (FISpH). Quantitative and qualitative methods assessed outcomes at three levels (process, outcomes and impact) at each stage of the implementation process (exploration, preparation, operation, sustainability). RESULTS: An advisory board with 10 representatives of key national stakeholders committed to supporting the study and 41 pharmacies were trained for Siscare. Of these, 33 (80%) had at least one of five implementation strategies in place 12 weeks after the start of patient inclusion and 27 (66%) have included ≥1 patient; mean inclusion per pharmacy: 8 (SD 6) patients [range: 1-29] with a total of 212 patients. Nine pharmacies (22%) met the target of 10 patients. An ordered three-step process of the implementation was observed in pharmacies: internal organisation, preparation of interprofessional practice, and relationship building with patients. Influencing factors were pharmacists' skills in motivational interviewing, support from pharmacy owners, pre-existing local interprofessional networks, and profitability of the programme. CONCLUSIONS: This implementation evaluation supports the feasibility and acceptability from the pharmacy team's perspective of Siscare. The programme's implementation on a wider scale is still difficult due to the inertia inherent in any fundamental change in practices and the economic-political uncertainties influencing the actors in primary care.

Protocol for an implementation and realist evaluation of a new organisational model for primary care practices in the canton of Vaud, Switzerland.

INTRODUCTION: Continuity of care, especially for patients with complex needs, is a major challenge for healthcare systems in many high-income countries, including Switzerland. Since 2015, a collaborative project between Unisanté-Department of Family Medicine (DMF), some general practitioners (GPs) and canton of Vaud's public health authorities has sought to develop a new organisational model for the provision of primary care to ensure better care coordination and to provide adapted care deliveries to patients' healthcare needs. The model's main component is the addition of a primary care nurse to GPs practices. Three additional tools are individualised patient care plans, electronic medical records and patient empanelment. To assess this model, a 2-year pilot study has begun in nine GPs' practices in the canton. This paper presents the protocol for an evaluation of the implementation and effectiveness of the new organisational model. METHOD AND ANALYSIS: We will conduct a before-and-after study using a mixed-methods and a realist approach. First, we will use quantitative and qualitative data to assess the new organisational model's implementation (feasibility, fidelity, acceptability and costs) and effectiveness (healthcare services use, patient experience, staff experience and patient-level costs). Combining this data with focus group data will enable a realist evaluation of the pilot project, which will help understand the elements of context and mechanism that affect implementation. ETHICS AND DISSEMINATION: The evaluation will inform the canton of Vaud's health authorities about the limits of and perspectives for this organisational model. All results will also be made available to the practices and the patients involved. At the end of the project, we will propose organisational adaptations and a sustainable financial model for extending the model to other practices in the canton and potentially to the national level.The canton of Vaud's Human Research Ethics Committee approved the study, and Data Protection and Information Law Authority gave a favourable opinion concerning data processing procedures.

Home-based subcutaneous immunoglobulin for chronic inflammatory demyelinating polyneuropathy patients: A Swiss cost-minimization analysis.

PURPOSE: To compare the cost of two patient management strategies with similar efficacies for chronic inflammatory demyelinating polyneuropathy (CIDP) patients in the chronic phase: hospital-based IV immunoglobulin G (IVIg) and home-based subcutaneous immunoglobulin G (SCIg) associated with an interprofessional drug therapy management programme (initial training and follow-up). METHODS: A 48-week model-based cost-minimization analysis from a societal perspective was performed. Resources included immunoglobulin (IVIg: 1 g/kg/3 weeks; SCIg: 0.4 g/kg/week initially and 0.2 g/kg/week in the maintenance phase), hospital charges, time of professionals, infusion material, transport and losses of productivity for patients. Costs were expressed in Swiss francs (CHF) (1 CHF = 0.93€ = US$1.10, www.xe.com, 2020/10/28). RESULTS: The total costs of IVIg were higher than those of SCIg for health insurance and other payers: 114,747 CHF versus 86,558 CHF and 8,762 CHF versus 2,401 CHF, respectively. The results were sensitive to the immunoglobulin doses, as this was the main cost driver. The SCIg daily cost in the initial phase was higher for health insurance than hospital-based IVIg was, but the additional costs were compensated during the maintenance phase (from week 28). The professional costs associated with the switch were not fully covered by the insurance and were borne by the pharmacist and the nurse. CONCLUSIONS: SCIg for CIDP patients reinforced by an interprofessional drug therapy management programme may be a cost-effective and sustainable alternative to IVIg in the Swiss system context. From an economic perspective, this therapy alternative should be more widely supported by healthcare systems and proposed to eligible patients by professionals.

Implementation and Effectiveness of an Interprofessional Support Program for Patients with Type 2 Diabetes in Swiss Primary Care: A Study Protocol.

This research protocol illustrates the use of implementation science to support the development, dissemination and integration in primary care of effective and sustainable collaborative pharmacy services for chronic care management. The objective is to evaluate the implementation and the effectiveness of a pharmacist-led patient support program including regular motivational interviews; medication adherence, patient-reported outcomes, and clinical outcomes monitoring; and interactions with physicians, for patients with type 2 diabetes taking at least one oral antidiabetic medication in the French-speaking part of Switzerland. This is a prospective, multi-centered, observational, cohort study using a hybrid design to assess the patient support program. The evaluation includes three levels of analysis: (1) the implementation strategies, (2) the overall implementation process, and (3) the effectiveness of the program. Qualitative and quantitative methods are used, and outcomes are assessed at each stage of the implementation process: exploration, preparation, operation, and sustainability. This research project will provide key insights into the processes of implementing patient support programs on a large scale and adapting the traditional community pharmacy practices towards the delivery of person-centered and collaborative services.

Implementation of an interprofessional medication adherence program for chronic patients in community pharmacies: how much does it cost for the provider?

BACKGROUND: The implementation of an innovative and sustainable professional pharmacy service in routine care requires substantial resources borne by the pharmacy owner. Although a community pharmacy is a business setting, few studies have examined cost as a potential barrier to widespread implementation. Implementation costs, as the cost impact of an implementation effort, can be significant and hamper the decision to invest from the provider perspective. Traditional financial planning tools can be used to analyse and support business decision to implement a service by assessing the net impact of a new service on the provider's budget. This study aimed to estimate the implementation costs and the break-even point of an interprofessional medication adherence program for chronic patients in Switzerland. The program combines motivational interviews, medication adherence electronic monitoring and feedback reports to patient and physicians. METHODS: We used a 3-step approach: (i) micro-costing analysis: identification of implementation activities, quantification and valuation of required resources. Implementation costs, including service support costs and direct delivery costs, were analysed according to the implementation phase (installation, initial implementation, and full operation); (ii) break-even analysis: estimation of the required number of patients to follow up with to ensure that the generated revenue exceeded the total cost; and (iii) univariate sensitivity analyses. RESULTS: The estimated total cost of the installation phase was 8481 CHF, more than half of which represented the cost of the equipment. Direct delivery costs were 666 CHF per patient per year, with 68% of this value associated with the cost of workforce time. According to the Swiss national reimbursement system, a minimal of 16 [10-27] patients was required to cover the implementation costs of the installation phase. This break-even point decreased to 13 patients in the initial and full operation phases. CONCLUSIONS: These estimates lead to a better understanding of the real cost of implementing a professional pharmacy service in routine care. In a Swiss context, the current medication adherence support fee-for-service system allows pharmacists to reach the break-even point. Such information is important for community pharmacists to guide their implementation strategies. The replication of similar analyses in other settings and countries is paramount.

Improving patient access to hepatitis C antiviral medicines in Switzerland: Understanding the financial risks for community pharmacies.

RATIONALE: As observed in other countries, some patients may experiment difficulties in obtaining their hepatitis C antiviral medicines (HCVm) in Swiss community pharmacies. There is a lack of data related to access to HCVm at the patient level and notably related to the potential financial risks for the community pharmacies. AIMS: (a) To evaluate the potential financial risks for community pharmacist associated with the delivery of HCVm in the Swiss healthcare system; (b) to explore the attitudes and experiences of community pharmacists related to these risks and their consequences for the patients. METHOD: A three-step approach was chosen as follows: (a) estimation of costs, incomes, and gross financial results directly related to 3-month treatment with Harvoni based on the drug delivery process (data from 68 patients over 2 years); (b) sensitivity analyses; (c) exploration of local community pharmacists' attitudes and experiences related to the delivery of HCVm in the canton of Vaud (Western Switzerland). RESULTS: Two main risks were identified: (a) Incomes do not always cover costs; (b) reimbursement issues could lead to an increase in the requirement for working capital. According to the survey, 23% (14/60) of pharmacies refused to deliver HCVm to at least one patient, and these patients had to find a solution mostly on their own. CONCLUSIONS: The scenario analysis clarifies the causes of the possible refusal to deliver HCVm. With the growing number of high-priced medicines, the healthcare systems should have a clear strategy to encourage their delivery by community pharmacies by ensuring seamless and collaborative care for patients. The community pharmacists could be accountable to provide such services-if they get the education, training, and remuneration.

Switching Patients to Home-Based Subcutaneous Immunoglobulin: an Economic Evaluation of an Interprofessional Drug Therapy Management Program.

PURPOSE: Home-based subcutaneous immunoglobulin (SCIg) therapy is an alternative to hospital-based intravenous infusions (IVIg). However, SCIg requires patient training and long-term support to ensure proper adherence, optimal efficacy and safety. We evaluated if switching patients to home-based SCIg including an interprofessional drug therapy management program (physician, community pharmacist and nurse) would be cost-effective within the Swiss healthcare system. METHODS: A 3-year cost-minimization analysis was performed from a societal perspective comparing monthly IVIg in an outpatient clinic and home-based weekly SCIg including an interprofessional program. Healthcare costs (immunoglobulin, professional time, infusion pump and disposables) were derived from administrative data. Transportation and productivity loss were estimated by expert opinion. The results were expressed in Swiss francs (CHF) and converted to Euros and US dollars (1 CHF = 0.92€, 1 CHF = $1.02; www.xe.com , 12/14/2015). RESULTS: Under base case assumptions, SCIg was estimated to cost 35,862 CHF (33,134€; $36,595) per patient during the first year and 30,309 CHF (28,004€; $30,929) in subsequent years versus 35,370 CHF (32,679€; $36,095) per year for IVIg. The total savings from switching to SCIg with the interprofessional program were 9630 CHF (8897€; $9828) per patient over 3 years. The results were relatively sensitive to the cost per gram of IgG, the cost of equipment and the annual number of infusions. CONCLUSION: Home-based SCIg including an interprofessional therapy management program may be an efficient alternative for patients. The program provides long-term support from self-administration training to the responsible use of therapy (proper adherence, optimal efficacy and safety). Over the short term, additional costs from purchasing equipment and the drug therapy management program were offset by avoiding hospital costs.

Expanding professional pharmacy services in European community setting: Is it cost-effective? A systematic review for health policy considerations.

OBJECTIVE: To synthesize cost-effectiveness analyses on professional pharmacy services (PPS) performed in Europe in order to contribute to current debates on their funding and reimbursement. METHODS: Systematic review in PubMed, Embase and the Centre for Reviews and Dissemination databases to identify full economic evaluation studies of PPS in community setting from 2004. FINDINGS: Twenty-one studies were included, conducted in the United-Kingdom (n=13), the Netherlands (n=3), Spain (n=2), Belgium (n=1), France (n=1) and Denmark (n=1). PPS to enhance medicine safety (interprofessional meetings to reduce errors, n=2) and access to medicines (minor ailment scheme, n=1) were in favour of their cost-effectiveness in the UK context, but the evidence is not sufficient. Eleven studies assessed PPS to improve treatment outcomes of individual patients-such as pharmaceutical care services, medication review, educational and coaching program, disease support service, medicines management and telephone-based advisory for improving adherence. Findings were contradictory and did not lead to strong conclusion. Screening programs for different diseases showed robust positive results (n=2) as well as smoking cessation services (n=5) and should be considered to be more widely available in accordance with national context. CONCLUSIONS: The review provides arguments for the implementation of PPS aiming to improve public health through screening programs and smoking cessation services. However, further full economic evaluations are needed to support or refute the added value of other services.

Effectiveness of intervention led by a community pharmacist for improving recognition of sleep apnea in primary care--a cohort study.

Despite its high prevalence and major public health ramifications, obstructive sleep apnea syndrome (OSAS) remains underdiagnosed. The aim of this study was to determine whether the involvement of a community pharmacist (CP) in the care pathway of a patient at risk of OSAS, through the implementation of a community pharmacist (CP) intervention, was effective, i.e. increased the use of diagnostic tests in this population. We compared a cohort of patients included in a research protocol (exposed to a CP intervention) with patients having the same characteristics taken from a general population database who did not receive the intervention (unexposed group). The aim of the CP intervention was to educate patients about the risk of untreated OSAS, encouraging them to consult their general practitioner, and urging the doctor to continue investigations. We included 782 patients at risk of OSAS, i.e. taking one or more anti-hypertensive drugs, being overweight (body mass index >25) and snoring almost every night (88 in the exposed group and 694 in the unexposed group). After a 6-month follow-up, the number of patients who underwent an OSAS diagnostic test was significantly higher in the exposed group compared to the unexposed group (22.7 versus 11.4%, P = 0.003). Being exposed to the pharmacist intervention was associated with a higher chance of undergoing a diagnostic test for OSAS, adjusted odds ratio: 2.24 (1.25-4.01). In conclusion, these findings provide arguments for the implementation of a CP OSAS screening intervention in CP routine practice.

Cost-Effectiveness of a Community Pharmacist-Led Sleep Apnea Screening Program - A Markov Model.

BACKGROUND: Despite the high prevalence and major public health ramifications, obstructive sleep apnea syndrome (OSAS) remains underdiagnosed. In many developed countries, because community pharmacists (CP) are easily accessible, they have been developing additional clinical services that integrate the services of and collaborate with other healthcare providers (general practitioners (GPs), nurses, etc.). Alternative strategies for primary care screening programs for OSAS involving the CP are discussed. OBJECTIVE: To estimate the quality of life, costs, and cost-effectiveness of three screening strategies among patients who are at risk of having moderate to severe OSAS in primary care. DESIGN: Markov decision model. DATA SOURCES: Published data. TARGET POPULATION: Hypothetical cohort of 50-year-old male patients with symptoms highly evocative of OSAS. TIME HORIZON: The 5 years after initial evaluation for OSAS. PERSPECTIVE: Societal. INTERVENTIONS: Screening strategy with CP (CP-GP collaboration), screening strategy without CP (GP alone) and no screening. OUTCOMES MEASURES: Quality of life, survival and costs for each screening strategy. RESULTS OF BASE-CASE ANALYSIS: Under almost all modeled conditions, the involvement of CPs in OSAS screening was cost effective. The maximal incremental cost for "screening strategy with CP" was about 455€ per QALY gained. RESULTS OF SENSITIVITY ANALYSIS: Our results were robust but primarily sensitive to the treatment costs by continuous positive airway pressure, and the costs of untreated OSAS. The probabilistic sensitivity analysis showed that the "screening strategy with CP" was dominant in 80% of cases. It was more effective and less costly in 47% of cases, and within the cost-effective range (maximum incremental cost effectiveness ratio at €6186.67/QALY) in 33% of cases. CONCLUSIONS: CP involvement in OSAS screening is a cost-effective strategy. This proposal is consistent with the trend in Europe and the United States to extend the practices and responsibilities of the pharmacist in primary care.

The future of pharmaceutical care in France: a survey of final-year pharmacy students' opinions.

BACKGROUND: In the last decades, the provision of pharmaceutical care by community pharmacists has developed in OECD countries. These developments involved significant changes in professional practices and organization of primary care. In France, they have recently been encouraged by a new legal framework and favored by an increasing demand for health care (increase in the number of patients with chronic diseases) and reductions in services being offered (reduction in the number of general practitioners and huge regional disparities). OBJECTIVES: This study aimed to investigate final-year pharmacy students' opinions on 1/expanding the scope of pharmacists' practices and 2/the potential barriers for the implementation of pharmaceutical care. We discussed these in the light of the experiences of pharmacists in Quebec, and other countries in Europe (United Kingdom and the Netherlands). METHODS: All final-year students in pharmaceutical studies, preparing to become community pharmacists, at the University Paris-Descartes in Paris during 2010 (n = 146) were recruited. All of them were interviewed by means of a questionnaire describing nine "professional" practices by pharmacists, arranged in four dimensions: (1) screening and chronic disease management, (2) medication surveillance, (3) pharmacy-prescribed medication and (4) participation in health care networks. Respondents were asked (1) how positively they view the extension of their current practices, using a 5 point Likert scale and (2) their perception of potential professional, technical, organizational and/or financial obstacles to developing these practices. RESULTS: 143 (97.9%) students completed the questionnaire. Most of practices studied received a greater than 80% approval rating, although only a third of respondents were in favor of the sales of over-the-counter (OTC) drugs. The most significant perceived barriers were working time, remuneration and organizational problems, specifically the need to create a physical location for consultations to respect patients' privacy within a pharmacy. CONCLUSIONS: Despite remaining barriers to cross, this study showed that future French pharmacists were keen to develop their role in patient care, beyond the traditional role of dispensing. However, the willingness of doctors and patients to consent should be investigated and also rigorous studies to support or refute the positive impact of pharmaceutical care on the quality of care should be carried out.