new zealand – can we live up to the ‘clean-green’ image?
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New Zealand – Can we live up to the ‘clean-green’ image?. Dr Rhiannon Braund School of Pharmacy University of Otago New Zealand. Pharmaceutical Policies In NZ. Strong focus on ‘access’ to medications (and healthcare in general). - PowerPoint PPT PresentationTRANSCRIPT
New Zealand – Can we live up to the ‘clean-green’
image?
Dr Rhiannon Braund
School of Pharmacy
University of Otago
New Zealand
Pharmaceutical Policies In NZ
Strong focus on ‘access’ to medications (and healthcare in general).
Individuals and families with lower income have reduced costs to see a Dr or to collect medications.
Pharmaceutical budget (~ $550 million p.a) maintained by a government agency (Pharmac) and they control the pharmaceutical schedule.
Collecting Prescription Medications
A prescriber writes a prescription for three months. Historically this was issued as one month and two
repeats. Patient paid a co-payment for first dispensing and
the additional two were at no cost, but could not collect them until at least 20 days had passed.
This co-payment was either $15, $3, $2 or $0 depending on income and number of items collected in a year.
What has changed?
In 2004, introduction of ‘stat’ or ‘all-at-once’ dispensing. – Save ~$60 million in dispensing/professional fees– ~$24 million in wastage– Overall savings of ~$36 million p.a
Recently (2007) the patient co-payment was reduced to $3 (NZD) for everyone.
↑ Access = ↑ Excess ?
If the obvious answer is yes, then the next question(s) are:– How much?– At what cost? (Clinical, Financial and
Environmental)– Can we minimize this excess without
compromising access?
Identification of returns (Study 1)
ODHB pay for the destruction of medications returned to pharmacies
A random sample of boxes for destruction were put aside for analysis
Almost 1300 kg returned in 9 month period Analysed 160 kg (12%)
Braund et al 2007 NZFP
Conclusion (Study 1)
All of the 20 most returned items = ‘stat’ but caution as ‘stat’ was intended to increase access
One patient returned– 1198 paracetamol– 1157 paracetamol/codeine– 469 doxepin 25mg– 362 warfarin tablets– 7 100g tubes of hydrocortisone
Why are they being returned (Study 2)
Previous overseas study found that those who returned medications brought back average of 60% of original prescription
The reasons included– Bereavement (26%)– Expired medication (25%)– Person felt better (11%)– Doctor changed medication (11%)– Allergic reactions (8%)– Person did not want to take the drug (7%)
Cameron S. 1996 Can Med Assn J
Situation in Dunedin (Study 2)
Pilot study Two local pharmacies Five week collection Patients returning medication for disposal
were asked to complete a brief questionnaire
Braund et al 2008 NZFP
Reasons for unused medications
Braund et al 2008 NZFP
Conclusions (Study 2)
Initiation of ‘trial’ prescribing Quantity of ‘prn’ medications
– Amount vs period of supply
One patient = ~ $15 000 worth of medication
Media Interest
Situation in Hutt (Study 3)
Approached by HVDHB to assist Used our surveys ‘The main objective of this programme was to
minimise the potential risk of household poisonings via safe and efficient methods of disposing unused medications.’
Question about medication storage added
31 community pharmacies Four week collection period 1605 bags returned 653 completed questionnaires Sample analysed (329 with 149
questionnaires) All Qs were also analysed
Returns by quantity
Ranking Generic Name Number Returned
1 Diclofenac Sodium 4462 S 2 Ibuprofen 4147 S 3 Levodopa 3521 S 4 Metformin HCl 3243 S 5 Aspirin 2839 S 6 Paracetamol Tablets 2743 S 7 Prednisone 2480 S 8 Codeine Phosphate 2348 9 Simvastatin 1727 S
10 Dextropropoxyphene HCl; Paracetamol 1639 11 Calcium Carbonate 1618 S 12 Omeprazole 1558 S 13 Loperamide HCl 1489 S 14 Amitriptyline 1455 15 Warfarin Sodium 1366 S 16 Metoclopramide HCl 1294 S 17 Cilazapril 1098 S 18 Naproxyn 1077 S 19 Docusate 1017 S 20 Metoprolol 872 S
Why was the medicine(s) not used?
‘Why was the medicine(s) not used?’
0
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Nu
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ort
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Figure 4. Number of reasons reported for returning medications (n=1254)
Conclusions (Study 3)
Trial prescribing ‘prn’ medications
Inhaler returns
Pharmac change in June 2008– Susan Judd
Storage and disposal survey (study 4)
Online Survey (via NZ poison centre)– Collecting medications– Collecting repeats– Storage – Disposal
Over a three month period 516 people viewed the survey and it was completed by 452 individuals
Results
62 % said that they currently had leftover or unwanted medications at home.
48 % of people store their medications in the kitchen, 29 % bathroom, 13 % bedroom
Disposal of unused
Response Medication Formulation Type Liquid Tablets/
Capsules Ointments/ Creams
Down the toilet 69 65 5 Down the sink 180 23 2 With household rubbish 106 223 339 Take it to the tip 4 6 22 Burn 2 11 9 Return to pharmacy 79 110 60 Give away 1 0 2 No answer 11 14 13
Reasons for unused medication
Condition re
solv
ed
Changed
trea
tmen
t
Exces
s su
pplied
Passe
d exp
iry d
ate
Side
effe
cts
Unsure
why
presc
ribed
Inco
nvenie
nce
Unclea
r inst
ruct
ions
Other
Patie
nt dec
ease
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300
350N
um
ber
of
Res
po
nse
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Why do you keep unused medications
In c
ase
needed
late
r
I don't
keep
them
Not sure
how to
dis
pose
Do not w
ant t
o was
te th
em
To kee
p a 's
tock
pile'
To giv
e th
em a
way0
50
100
150
200
250
Nu
mb
er o
f R
esp
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ses
Where to from here?
In 2009, will start analysis of different water systems to determine if trace levels of pharmaceuticals
Also ‘life of a prescription’ study. This will investigate what types of medications are not collected, used etc
Acknowledgements
Community Pharmacists Undergraduate Pharmacy Students
NZPERF NZ National Poison Centre