The benefit of a healthy lifestyle and pharmaceutical consumption

We have become accustomed to turning to our very well-stocked medicine chests or if that fails us, to our friendly pharmacist for immediate  relief to all our ailments. This tendency has led us to be symptomatic  in our treatment of disease, rather than attempting to get to the root of the problem. 

It is unfortunate that this attitude has crept into  the manner in which health professionals approach most medical  problems presented by patients. The quick fix consists of а prescription, or in the case of a pharmacist a recommendation for а particular drug or referral to a certain physician. This has led to an  increase in the demand for medical services and pharmaceutical  products, with a concomitant increase in the financial pressures on  the payer, whether the cost is state-financed or paid out-of-pocket.

It is quite likely that a percentage of patients being treated with  lipid-lowering pharmaceutical therapies and anti-hypertensive  medication, would achieve the same or improved treatment outcomes, without treatment(or at least at a lower dose and variety), if induced  to adopt lifestyle changes that are conducive to better health. In  other words, if the patients on the above mentioned drugs are  overweight, smoke and possibly consume amounts of alcohol that аре above the recommended limits, then there is room for improvement. Persuading these people, indeed the whole of the Maltese population  that lifestyle and positive health outcomes are inexorably linked, would be beneficial to all of society as a whole.

In fact, not only would patients be better off if they required less  or no medication, they would also reap the benefits of an improved  well-being and healthy outlook. Society at large would gain, and the  state would also see a reduction in the increase in pharmaceutical  expenditure that is threatening to derail the whole public healthcare  system.

The subject requires a much deeper and considered discussion, but one  cannot discount and ignore the positive effects of combining health  promotion and prevention together with treatment. It is unfortunate  that, especially locally, we are dedicating most of our efforts and  funding towards the latter, and ignoring the long-term benefits that  the former could provide.

Professional morals and education

It is all so easy for members of the health professions to forget the true reason for their daily work routine. All health professionals are inexorably linked to the principles of patient primacy and the over-riding moral authority derived from the Hippocratic oath and related philosophies. Unfortunately financial matters and other conflicts have come to exert ever increasing pressures on practitioners in various fields. This has lead to a situation where the health of the patient is no longer the primary concern, but takes second place to career advancement, profiteering or a combination of both.

It is imperative that institutions of higher education place great emphasis on the creation of graduate professionals, that are not only of a high academic standard, but also of strong moral fibre. Such a task is no mean feat, as persuading students who are just about to attempt to establish a foothold in the societal rat-race, that principles are worth more than financial reward, is a tall order.

The first step in achieving the above is to have educators that practice and hold themselves to the same standards that students aspire to. As is often the case, remuneration within the academic world does enable universities to hold on to,or attract the best talent available. In certain cases it might make sense to utilise a system of visiting lecturers from various specialities, or create a pool of volunteers from leading professionals who would dedicate a certain amount of time to mentoring.

Attaining a high level of moral standards and ethical practice within the pharmacy profession will enable the possibility of self-regulation with respect to a multitude of issues that need to be approached. This in turn will create the opportunity to negotiate with other stakeholders and indeed patients themselves, from the vantage point of moral high ground.

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End of year thoughts!

End of year thoughts!

Firstly I would like to wish a Happy New Year to all health professionals, their families and patients. I would also like to pass on my regards to my colleagues and team members at UDKA Company Limited; I consider myself lucky to have such a competent and pleasant set if people with whom to work. I would also like to include the University of Malta Third Year students, who have provided me with much inspiration in our weekly lectures and also all members of the Pharmacy Department.

God willing, we will all strive to ensure a satisfying and goal-driven 2012.

John

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Cost/effect evaluation in pharmaceutical care

The development of a set of of indicators that enable the evaluation of expenditure in pharmaceutical care is pivotal to the local state funded healthcare system. The considerable rise in expenditure observed in the last 10 years or so cannot simply be attributed to demographic shifts or an increase in non-communicable disease, even though these two factors have contributed somewhat to exacerbate the situation. Without a comprehensive set of comparator milestones, administrators are served a poisoned chalice, only able to state their expenditure, having no standard set of outcomes measures against which to grade potential system improvements, or extract cost/effect ratios.

Continous increases in expenditure are coupled with budgetary considerations, which are all the more relevant in current times. Fiscal caution and a healthy respect for the value of monies invested and spent has taken over the general public consciousness; as often is the case with human nature, this was a result of the 2008 financial crash and the rude awakening that followed, rather than a self applied act of regulation. The need for all of humanity to exercise restraint and judgment with respect such matters was long overdue, and this has now spilt over into the world of healthcare administration, with the Maltese Islands being no exception.

The greatest obstacle encountered when considering the above subject is the fact that no hard and fast indicators for the cost/effect of pharmaceutical expenditure exist. A direct result of pharmaceutical expenditure is the provision of pharmaceutical care, as defined in the classical manner by Hepler and Strand; if this definition is to be taken literally, problems immediately arise. Very few countries have integrated the principles of pharmaceutical care fully into the fabric of their healthcare systems; the reasons for this are many, but include a lack of funding to implement the required changes to intervention procedures, a lack of healthcare professionals trained in such practice, and a lack of political and administrative will to push through with the reform necessary. This in itself is the first hurdle that must be overcome, especially when one begins to consider the local case. Pharmaceutical care forms a central part of the training of pharmacists within the curriculum of the pharmacy department at the University of Malta, however it has yet to be introduced in a full-scale scenario at Mater Dei General and also integrated into the system for the provision of medicines through the state-funded framework.

Quite likely, one would have to consider a batch of surrogate markers or end-points instead; the obvious and reasonable objection to such an approach would be that of proving causality, since a link between expenditure in one area and a related change in a health outcome might not necessarily mean that the first was the reason for a change in the latter, even though the two would be correlated.

An ideal scenario would be one where the possibility of a clean slate existed, and one would be able to start afresh, implementing a holistic treatment and outcome evaluation paradigm. This, however, is a Utopian pipe-dream, as reality is somewhat more complex and fraught with complexity. Without delving into the administrative and political intricacies that are necessary sequelae of such a movement of change, primary emphasis must be placed on the training of the instigators of such change. Focus must be initially concentrated on the principles to be adopted and engraved into the DNA of the health professionals involved; without a change in the mindset of the innovators and their interdisciplinary team nothing worthwhile can be achieved within a relatively short time frame. In the absence of this, we would have to settle for incremental change, which would no yield temporally beneficial results to the citizens of the Maltese Islands.

Thus the first steps to be taken are the training of more dedicated and specialized pharmacoeconomic personnel, with the remit of the development, refinement and application of pharmaceutical care indicators. This would enable us to obtain a clear picture of the current efficiency of pharmaceutical financing and permit the framing of more cost-effective constructs, which as I stated earlier, is all the more relevant in the financial climate that governs our times.

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Time for action before it is too late!

The diagram below shows us very bad news! According to the latest statistics made available by the National Statistics Office (Malta), 41% of the local population is overweight and 21% classified as obese.

Whilst this may be a source of amusement to some, it is of great concern from a healthcare administration point of view. Higher rates  of obesity are leading to  a higher incidence of diabetes mellitus, cardiovascular disease (CVD) and metabolic syndrome. CVD is already the primary cause of morbidity in the Maltese Islands, and even though data is not available presently, it is also quite likely the cause of the greatest proportion of per capita healthcare and pharmaceutical expenditure. Any increase in demand to an already straining and over-stretched public healthcare system is going to lead to disaster.

Unfortunately that is where we are heading. A comprehensive, cohesive and all-inclusive(re the health professionals and public and private sector NGOs and other organisations) national plan is required before it is too late. The money voted in the last few year s for a national campaign against obesity (€ 200,000) is insignificant in comparison to the task at hand. If necessary, unhealthy foods could be subjected to an additional surcharge, or at the least, the suppliers of foods above a certain calorific value could be forced to contribute to a fund utilised in health promotion campaigns. Schools, whether public or private should have strictly enforced physical education sessions, at a minimum number per week, with non-attendance a failing point, except for medical exemptions.

Despite the financial caution placed upon us by the times we live in, money must be invested now in order to safeguard the future of our generation and those to come after us, otherwise the healthcare system we know today will cease to exist, crushed under the epidemic of CVD disease that is just round the corner!

The pharmacist as an administrator

Administration and management are facets of the pharmacy profession that often disregarded, or at least relegated to a footnote at the end of minor credits, within the context of pharmacy undergraduate courses. They are, however, vital skills within our multiple-disciplinary mindset, especially in the context of the Maltese Islands.

One must consider that amongst most pharmacists that enter the field of community practice, most are required to carry out the duties of professional pharmacist and shop manager. These duties require as a bare minimum a working knowledge of administrative functions and procedures.

This point of argument is also relevant outside the area of community practice, as in the running a state owned pharmacy, or the management of the budget and expenditure of a pharmaceutical distributor. Such duties still impose the supposition of the knowledge of money and people management. Even though one might argue that management and administrative duties do not fall within the remit of a pharmacist's core responsibilities, one would be short-sighted and very blinkered not to recognize the possibilities, both from a career-ameliorating aspect, and also from that of personal satisfaction, that could be realized with the addition of management and administrative skills to the pharmacist's already broad knowledge base.

One might even argue for a greater focus at undergraduate level on such matters, and the possibility of a post-graduate specialization in healthcare administration, possibly in co-operation with the faculty of management and accountancy. Integrating a high level of functionality and versatility into the pharmacist's repertoire of skills will set up future graduates on a better footing for professional and personal success in the long haul.

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Generic medicines in Malta

The low market penetration and the consumer's lack of information about generic medicine products was highlighted by a survey carried out last year by the Malta Medicines Authority, from which it transpired that over 80% of the general population had no idea what generic medicines really meant.

This is of great import to the general discussion on the very hot topic of medicine prices, as price variations in generic and branded products can be substantial, especially when one considers that a considerable amount of new products have been introduced to the Maltese market in the past year.

Below is an unpublished opinion piece written last year on the subject. The link to pdf file is here:http://www.stsimonpharmacy.com/Docs/In%20defence%20of%20the%20Pharmacist%20II.pdf


Generic Medicines and lower prices!

Most members of the public do not have a clear idea of what the term generic constitutes when applied to the context of medicinal products. This short article aims to correct this lack of information, and also provide points on how a Maltese consumer can obtain the therapeutic benefits provided by modern medicines whilst saving on expenditure.

A generic medicinal product is a version of a previously patented (that is protected by a monopoly licence) medicine, that is identical to it in composition and action. In most cases the generic product is cheaper than the originator product. Locally, one can draw comparisons between the prices of generic paracetamol(€ 2 per 100) and the branded version(€ 1.61 per 24).

A generic version is just as safe and effective as the originator and passes all the minimum quality requirements that are demanded by the European Medicines Agency (EMEA), and also the Malta Medicines Authority. Maltese legislation allows brand substitution of prescribed products unless the physician expressly prohibits this on the script. In certain cases a pharmacist is morally obliged to point out the availability of cheaper alternatives to the patient, as the savings can be substantial. For example, in the case of a particular proton pump inhibitor (for stomach acidity), the variance between the originator and generic for a six-month prescribed course from Mater Dei General Hospital is a whopping € 277!

Not all generic drugs provide savings of the magnitude described above, and in certain cases the difference may not be significant enough to warrant changing brand, especially in the case of chronic medication and elderly patients. However it is imperative that the patient is aware of the existence of equivalent and cheaper alternatives, as this will increase the access of the general public to pharmaceutical treatment and lead to a better quality of life. No patient should object to paying a high price for a newly discovered and cutting edge drug treatment; on the other hand, it is every patient’s and Maltese citizen’s right to have access to the same treatment at much reduced prices once the monopoly period of manufacture has expired.

All patients have the right to demand the existence of an alternative medicine, and if this is available, take the decision on whether or not to migrate to a more cost-effective healthcare solution. The role of the pharmacist is to point out the existence of such alternatives, and provide professional and unbiased advice on the best treatment option to be chosen, as cheaper is not always necessarily better!