Key elements for the education and counselling of patients treated with oral anticancer drugs.

PURPOSE: The process of education and counselling of patients treated with oral anticancer drugs, aimed to achieve adequate self-management, involves different stakeholders (i.e. physicians, oncology nurses, pharmacists) from primary and secondary care. However, currently no guiding principles exist on how to organize and perform education and counselling for these patients. Therefore, the purpose of this study was to develop and build consensus on key elements for the education and counselling in patients on oral anticancer drugs. METHODS: A multi-method approach combining a literature search, semi-structured interviews with patients and healthcare professionals, and input from experts were used to develop an initial list of key elements. Subsequently, consensus was built in a two-round Delphi-study, involving patients and healthcare professionals from primary and secondary care. Key elements were retained if at least 80% of respondents in all groups considered the element as important or if in at least one group 90% consensus was reached. RESULTS: The initial list contained 110 key elements, divided in 7 themes: coordination of care, patient contacts: style and content, medication counselling at the start of the treatment and during follow-up, psychosocial support, and involvement of family and friends. After the first Delphi round, 80% consensus was reached for 23 elements; 6 new key elements were added. After the second round, 80% consensus was reached for 51 out of 116 elements; 31 elements were added following the 90%-rule, yielding a list of 82 elements. CONCLUSION: The final list of 82 key elements, obtained in this study, could be used to develop clinical pathways that guide adequate education and counselling of patients on oral anticancer drugs. Due to the open description, the implementation of these elements can be adapted to the specific context and composition of the oncology team.

Information on antidepressants for psychiatric inpatients: the divide between patient needs and professional practice.

BACKGROUND: Medicine information is an integral part of patient care and a patient right. In particular, patients with a mental health diagnosis have a need for information on medicines. OBJECTIVE: This study aims to describe the current practice on information provision on antidepressants to inpatients in psychiatric hospitals. METHODS: A qualitative study was conducted consisting of semi-structured interviews with health care professionals (n=46) and patients (n=17) in 11 Flemish psychiatric hospitals. Two topic guides were designed for conducting the interviews with these respective stakeholders. The issues addressed in the topic guides related to: organization of information provision in the hospital, information on demand of the patient, information provision by health care professionals, information for relatives, evaluation of provided information, interdisciplinary contacts on information provision and satisfaction on current practice of information provision. The interviews were analysed according to the five stages of the framework analysis. RESULTS: Psychiatrists and nurses are the key players to provide information on antidepressants. Their approach depends on patient characteristics and mental state. Information is provided mainly orally. Health care professionals consider non-verbal cues of patients to verify if information has been understood. Health care professionals reported lack of time and lack of interdisciplinary contacts as negative aspects. Patients indicated that health care professionals take too little initiative to provide medicine information. CONCLUSIONS: Patients are informed about their antidepressants through various pathways. Although the awareness is present of the importance of the individual approach and efforts are done to tailor information to the individual patient, improvement is still possible. Tailoring communication; assessing patient needs and preferences; matching of health care professional style and patient needs; and achieving concordance, is a complex and challenging task for health care professionals in mental health care.

Detecting pre-diabetes and the role of the pharmacist.

OBJECTIVE: This study aims to use a pharmacoepidemiological approach to study the drug use of patients during the year prior to diabetes diagnosis (i.e. pre-diabetic patients) and control patients. Drug use might reveal cardiovascular, metabolic and/or endocrinological changes and help to identify indicators for active monitoring of Type 2 diabetes mellitus. METHODS: A retrospective case-control study compared drug use of patients with a future diagnosis of diabetes (experimental patients) with patients without a diabetes diagnosis (control patients) based on community pharmacy records. An experimental patient had used oral hypoglycaemic drugs during 2005 or 2006. Experimental and control patients were matched in terms of age, gender and quarter of index date. Drugs were selected based on possible co-morbidities of diabetes. Drug use was expressed as a binary variable, indicating whether or not a patient took specific drugs. Drug use was compared between experimental patients during the year prior to diagnosis and control patients using the chi-squared test. RESULTS: Our dataset covered 5,064 patients (1,688 experimental and 3,376 control patients). A higher probability of taking cardiovascular drugs was observed for specific subgroups of patients with pre-diabetes as compared to control patients: this trend was observed for men as well as for women, for various cardiovascular drug classes, and for different age groups (p<0.05), although it was not always statistically significant for the 29-38 age group. For each selected age and gender group, patients with pre-diabetes had a higher probability of taking a combination of a lipid-modifying agent and an antihypertensive drug than control patients (p<0.005). CONCLUSIONS: Using community pharmacy data, this study demonstrated that age and a characteristic drug use pattern could contribute to detecting pre-diabetes. There is a potential role for community pharmacists to follow up drug indicators of patients with a view to refer high-risk people for screening by a physician.

Cardiovascular drug use prior to diagnosis of diabetes: a pilot study in community pharmacy.

OBJECTIVES: The literature indicates that cardiovascular drug use is higher during the years prior to diagnosis of type 2 diabetes mellitus. As there are pharmaco-epidemiological and economic consequences of enhanced medication use prior to diagnosis of diabetes, there is a need for a comparative analysis of the drug-use pattern by patients with a subsequent diagnosis of diabetes and control patients. This pilot study aimed to investigate cardiovascular drug use in patients with a subsequent diagnosis of diabetes using data extracted from 200 community pharmacies in the Belgian township of Hasselt. METHODS: Based on community pharmacy data, a retrospective case-control study compared the drug use of patients with a subsequent diagnosis of type 2 diabetes (cases) with patients without a subsequent diagnosis (controls). Cases were identified if patients started taking metformin (and possibly other drugs used in diabetes) during the 2004-2006 study period. Drug use was expressed as a binary variable, reflecting whether or not a patient took drugs belonging to a specific cardiovascular subclass. KEY FINDINGS: Our dataset consisted of 158 cases with a subsequent diagnosis of type 2 diabetes and 632 control patients. Patients with a subsequent diagnosis of type 2 diabetes had a higher propensity to take cardiovascular drugs prior to diagnosis than control patients. This trend was observed across all cardiovascular drug classes, except for calcium-channel blockers, and was statistically significant for beta-blocking agents and agents acting on the renin-angiotensin system. CONCLUSIONS: A positive association was observed between cardiovascular drug use and subsequent diagnosis of type 2 diabetes. This study emphasizes the potential role for community pharmacy in early identification of diabetes using more targeted screening based on cardiovascular drug use as derived from pharmacy databases.

International comparison of orthotic brace prices.

This study compared market prices (i.e. third-party reimbursement and patient co-payment) of prefabricated neck, wrist and knee braces in Belgium, France, the Netherlands, Ontario (Canada) and the UK. Data were collected through contacts with health authorities, health insurance funds, manufacturers and distributors. Market prices varied substantially between countries, indicating that manufacturers adapt their price setting strategy to the policy environment and the structure of the brace market of a country. Belgian prices tended to exceed prices in other countries for the selected neck, wrist and knee braces. There seems to be scope for reducing Belgian prices of selected braces.

Reforming the Belgian market for orthotic braces: what can we learn from the international experience?

OBJECTIVES: This article aims to review regulation governing outpatient orthotic braces (neck, wrist and knee braces) in France, the Netherlands and Sweden with a view to reforming the Belgian market. METHODS: Information about the regulatory framework was derived from an analysis of legal texts and a survey completed by national experts. RESULTS: Strategies to keep down prices include public procurement in Sweden, maximum prices in France, and exclusion of expensive braces from reimbursement in the Netherlands. Reimbursement is linked to a medical indication or a chronic condition in France, the Netherlands and Sweden. To gain reimbursement, the cost-effectiveness of orthotic braces needs to be demonstrated in France and the Netherlands. Orthotic braces tend to be initially prescribed by a specialist physician and distributed by orthotists, medical equipment shops and/or community pharmacies. CONCLUSIONS: Extensive government intervention exists in the outpatient orthotic brace market in the countries studied. Our recommendations to reform the Belgian market for prefabricated orthotic braces are to separate reimbursement for service provision from reimbursement for braces; to set prices by means of a tendering process or an international price comparison; and to make reimbursement conditional on effectiveness and cost-effectiveness of braces.

Do tariffs and prices correspond with costs? A case study of orthotic braces.

OBJECTIVES: The Belgian third-party payer wishes to set reimbursement tariffs at a level that reflects the costs of orthotic braces. This article aims to calculate production and distribution costs of a prefabricated hard neck and knee brace and to explore whether Belgian tariffs and actual retail prices correspond with estimated costs of these two braces. METHODS: The cost model considered manufacturing costs, general overheads, research and development costs, warehousing costs, profit and distribution margins. Data were gathered from manufacturers, a production site visit, desk research, a decomposition of finished products and stakeholder interviews. The price year was 2007. RESULTS: The cost model estimated a retail price of euro55-euro150 for the neck brace, depending on assumptions. The estimated retail price for the neck brace was lower than the reimbursement tariff of euro194 and the actual retail price of euro241. The estimated retail price of euro331-euro694 for the knee brace was lower than the actual retail price of euro948. CONCLUSIONS: Actual retail prices and reimbursement tariffs for a neck brace and a knee brace exceeded prices based on estimated costs. Therefore, there appears to be scope for reducing tariffs.

Use and costs of anti-secretory and cardiovascular co-medication in osteoarthritis patients treated with selective or non-selective NSAIDS.

OBJECTIVE: This study aims to compare use and costs of anti-secretory and cardiovascular co-medication in osteoarthritis patients treated with selective or non-selective NSAIDs. METHOD: A retrospective study examined Belgian patients aged 65 years or more who suffer from osteoarthritis and are chronic users of selective NSAIDs (n=1,376) or non-selective NSAIDs (n=8,482). A before-and-after analysis compared drug use and costs between period 1 (first 6 months of 2002) and period 2 (several 1-year periods stretching over 2003-2004). A cohort analysis contrasted patients taking selective NSAIDs with patients taking non-selective NSAIDs. MAIN OUTCOME MEASURES: Anti-secretory co-medication included histamine H2-receptor antagonists and proton pump inhibitors. Cardiovascular co-medication referred to cardiac glycosides, anti-arrhythmics, anti-thrombotics, anti-angina drugs, anti-hypertensive drugs and serum-lipid-reducing drugs. Volume of drug use was expressed as number of packages and costs were computed in Euro. RESULTS: The volume of anti-secretory co-medication increased by 36% with selective NSAIDs and by 55% with non-selective NSAIDs between periods 1 and 2. Cardiovascular co-medication rose by 18% with selective NSAIDs and by 12% for non-selective NSAIDs. Focusing on patients who did not take anti-secretory co-medication in period 1, patients taking selective NSAIDs were just as likely to start anti-secretory co-medication in period 2 as patients taking non-selective NSAIDs (odds ratio: 1.05; 95% confidence interval: 0.90-1.23). Patients taking selective NSAIDs were just as likely to start cardiovascular co-medication as patients taking non-selective NSAIDs (odds ratio: 1.03; 95% confidence interval: 0.78-1.36). Annual costs of treating osteoarthritis in ambulatory care amounted to 756 with selective NSAIDs and 416 with non-selective NSAIDs. This originated from higher acquisition costs (278 vs. 24 ) and higher costs of co-medication (477 vs. 392 ) with selective NSAIDs. CONCLUSIONS: The use of selective and non-selective NSAIDs is accompanied by a higher use of co-medication over time. The increase in anti-secretory co-medication was more prominent with non-selective NSAIDs. The rise in cardiovascular co-medication was more pronounced with selective NSAIDs. Treatment of osteoarthritis with selective NSAIDs is more expensive than with non-selective NSAIDs in terms of acquisition costs and costs of co-medication.