Evolución en la Prestación de Servicios de Salud: Implicaciones e Impacto en la Profesión de

Farmacia y Servicios de Cuidado Farmacéutico

Dr. José J. Hernández

Centro de Información de Medicamentos e InvestigaciónEscuela de Farmacia

Universidad de Puerto Rico

BOSQUEJO• DEFINICIÓN E HISTORIA DEL CUIDADO

AMBULATORIO • TIPOS DE PRACTICA MÉDICA

• CUIDADO DIRIGIDO• PAGO POR SERVICIO

• LUGARES DE PRÁCTICA TIPO AMBULATORIA• NO-INSTITUCIONAL• INSTITUCIONAL• SERVICIOS DE EMERGENCIA• GOBIERNO• PRACTICA DE FARMACIA AMBULATORIA

• ESTADÍSTICAS VITALES DE PUERTO RICO• TENDENCIAS DE CUIDADO AMBULATORIO EN

GENERAL Y EN FARMACIA

CUIDADO AMBULATORIO

• DEFINICIONES:

– “CUIDADO PROVISTO A PACIENTES NO-INSTITUCIONALIZADOS” (SHAPER, 1999)

– “CUIDADO A PACIENTES QUE VAN VOLUNTARIAMENTE CAMINANDO A BUSCAR SERVICIOS DE SALUD” (WILLIAMS, 1999)

PERSPECTIVA HISTÓRICA

• SOCIEDADES PRIMITIVAS

– MÉDICO BRUJO

– MÉDICO DEL VECINDARIO

• SOCIEDAD MODERNA

– AUMENTO EN ESPECIALIZACIÓN

– EQUIPO TECNOLÓGICO

PERSPECTIVA HISTÓRICA

• HOY DÍA:

– CUIDADO BASADO EN OFICINAS MÉDICAS: MENOS MÉDICOS VIAJAN A LOS HOGARES DE LOS PACIENTES.

TIPOS DE PRACTICA MÉDICA

• PAGO POR SERVICIO– NO TOPES DE PAGO

– PACIENTE PAGA POR TODOS LOS SERVICIOS RECIBIDOS

• PROGRAMAS DE CUIDADO DIRIGIDO– MINIMIZAR COSTOS

– PAGOS FIJOS

• COMIENZO DE PROGRAMAS DE CUIDADO DIRIGIDO

– EL SISTEMA DE PAGO PROSPECTIVO DE MEDICARE PARA HOSPITALIZACIONES

– IMPLEMENTADO EN 1983– ACORTAR ESTADÍA EN HOSPITALES– DESARROLLARON PROGRAMAS DE CUIDADO

AMBULATORIO

DIFERENTES NIVELES DE SERVICIO DE CUIDADO AMBULATORIO

• SERVICIOS PREVENTIVOS

– CLÍNICAS DE CERNIMIENTO (HIPERTENSIÓN, DIABETES, O CÁNCER)

– PROGRAMAS DE VACUNACIÓN

• SERVICIOS PRIMARIOS

– SE PROVEE CUIDADO DE RUTINA A LOS PACIENTES (EJ., DIAGNOSTICO, TRATAMIENTO)

– A CARGO DEL MÉDICO PRIMARIO

• SERVICIOS SECUNDARIOS Y TERCIARIOS

– SE PROVEE CUIDADO ESPECIALIZADO A LOS PACIENTES A NIVEL AMBULATORIO E INSTITUCIONAL

– REQUIERE EL USO DE EQUIPO COMPLEJO Y PERSONAL ALTAMENTE ADIESTRADO

LUGARES DE PRACTICA AMBULATORIA

• NO-INSTITUCIONAL (PRACTICA BASADA EN OFICINA)

• CUIDADO AMBULATORIO INSTITUCIONAL

• CUIDADO AMBULATORIO DE EMERGENCIA

• PROGRAMAS DEL GOBIERNO

• FARMACIAS DE COMUNIDAD

Ambulatory Practice Settings

I. Non-institutional settings (Office-based practice)

Solo practice: decreasing in numbers

Group practice

• An affiliation of three or more providers

• Share income, expenses, facilities, equipments, medical records, and support personnel.

Ambulatory Practice Settings

II. Institutional settings

1. Hospital/ Teaching Hospital clinics

• Focus shift

• VA medical centers

– Pharmacists in ambulatory care

Inpatient care

Research

Specialty clinics

Outpatient care Increased role for

the primary care

practitioner

Ambulatory Practice Settings

II. Cont’d

2. Ambulatory surgical centers

Provide one-day surgical care at reduced cost and time

3. Other outpatient services

Diagnostic-imaging center

Home intravenous services

Home health care services

Ambulatory Practice Settings

III. Emergency medical services1. Hospital emergency services Increasing use of the ER for primary care

Referral based on cases: nonurgent, urgent, emergent cases

2. Emergency medical services Incorporation with hospital ER, transportation,

and communication systems

Specialized ambulance services (ex. Shock-trauma vans)

3. Emergi-Centers Care for urgent and non-urgent cases

Ambulatory Practice Settings

IV. Government programs

1. Public health services

Communicable disease control

Maternal and child health services

Chronic diseases

General ambulatory care

2. Neighborhood health centers

Targeted to prevalent disease and low income level

Ambulatory Practice Settings

IV. Government programs cont’d

3. Indian health services

Clinical pharmacist: pharmacist as a primary care provider

1) Patient counseling on Rx meds

2) Primary care program developed

3) Direct access to the patient’s chart

• Patient’s history taking

• Physical assessment

• Prescribing treatment and medications

Ambulatory Practice Settings

V. Ambulatory pharmacy services1. Hospital outpatient clinics Changes of approach

Pharmacist-managed clinics

• e.g., diabetes, lipid, or anti-coag clinics

• Improvement in patient compliance and follow-up appointments

Centralized

Inpatient

pharmacy

Decentralized

Outpatient

pharmacy

Ambulatory Practice Settings

V. Ambulatory pharmacy services; cont’d

2. Primary care and family practice clinics

Pharmacist as an interdisciplinary team member

• e.g., diabetes, lipid, or anti-coag clinics

• Impact

Improvement of physician efficacy

Reduction of adverse drug reactions

Improvement of quality of care

Improvement of compliance

Ambulatory Practice Settings

V. Ambulatory pharmacy services; cont’d

3. Community pharmacy

“Expanded” role of the pharmacist: dispensing and patient care

Pharmaceutical care for improved outcomes

Educate patients about their diseases

Medication compliance/ therapy

Identify and decrease ADR

Decrease misuse and abuse

Patient satisfaction

Ambulatory Practice Settings

V. Ambulatory pharmacy services; cont’d Supply of pharmacists

A total of 243,000 pharmacists were actively practicing in 2006.

* Other areas =clinics, MCOs, mail order pharmacies, long-term care, home

health care, pharmaceutical company, academia, the federal government, etc.

*

Source: Bureau of Labor Statistics. Pharmacists. Occupational outlook handbook,

Washington, DC: US Department of Commerce, May 04, 2009.

Puerto Rico 2010

Población

3,894,855

Matrimonios

23,650

Divorcios

15,197

Nacimientos

51,239

Muertes fetales

537

Defunciones

29,066

Corazón

5,031

Cáncer

4,898

Diabetes

2,569

CV

1,532

Alzheimer

1,211

Otras

13,894

Muertes

Infantiles

416

Madres

solteras

28,320

Bajo peso

5,872

Madres

Adolescentes

9,299

Un Día en Puerto Rico 2010

Población

3,894,855

Matrimonios

65

Divorcios

42

Nacimientos

140

Muertes fetales

1.5

Defunciones

80

Corazón

14

Cáncer

13

Diabetes

7

CV

4

Alzheimer

3

Otras

38

Muertes

Infantiles

1

Madres

solteras

77

Bajo peso

16

Madres

Adolescentes

26

Causas de Muerte en PRC

ondic

ión

Expectativa de Vida en P.R.

National Ambulatory Medical Care Survey (NAMCS)

• What is NAMCS?

– An annual survey; public database

• What information does it provide?

– Big picture: national pattern and/or trend

– Characteristic of patients (gender, age, ethnicity, insurance type, etc)

– Conditions most often treated (diagnoses, prescribed medications, etc)Link: http://www.cdc.gov/nchs/ahcd.htm

Trends in key physician office visit characteristics, 1992-2001

Source: Cherry DK, et al. National Ambulatory Medical Care Survey: 2001 Summary.

Advance data from vital and health statistics; no. 337. Hyattsville, Maryland: National

Center for Health Statistics. 2003.

Trends in office visit rates by patient age: United States, 1994-2004

Source: Hing, E. et al. National Ambulatory Medical Care Survey: 2004 Summary.

Advance data from vital and health statistics; no. 374. Hyattsville, Maryland: National

Center for Health Statistics. 2006.

Rank Most Common

Principal Diagnosis

Percent

Distribution

1 Essential Hypertension 4.2

2 Routine infant or child health check 3.4

3

4

Malignant Neoplasms

Acute upper respiratory infections,

excluding pharyngitis

3.0

3.0

5 Diabetes mellitus 3.0

6 Arthropathies and related disorders 2.7

7 Spinal disorders 2.6

8 Normal pregnancy 2.5

9 Rheumatism, excluding back 2.0

10 Specific procedures and aftercare 1.7

Most Common Diagnoses, 2004

Source: Hing, E. et al. National Ambulatory Medical Care Survey: 2004 Summary.

Advance data from vital and health statistics; no. 374. Hyattsville, Maryland: National

Center for Health Statistics. 2006.

1990 Rank 2004

Essential hypertension 1 Essential hypertension

Normal pregnancy 2 Routine infant or child health

check

Otitis media 3 Malignant Neoplasms

General medical examination 4 Acute upper respiratory

infections, excluding pharyngitis

Acute upper respiratory

infections

5 Diabetes mellitus

Health supervision of child 6 Arthropathies and related

disorders

Diabetes mellitus 7 Spinal disorders

Allergic rhinitis 8 Normal pregnancy

Bronchitis 9 Rheumatism, excluding back

Most Common Diagnoses; 1990 vs. 2004

Rank Therapeutic

Classification

Percent

Distribution

1 Antidepressants 5.1

2 NSAIDs 4.7

3 Antiasthmatics or bronchodilators 4.4

4 Antihypertensive agents 4.4

5 Hyperlipidemia 4.1

6 Antihistamines 3.7

7 Acid or peptic disorders 3.6

8 Antiarthritics 3.5

9 Blood glucose regulators 3.4

10 Non-narcotic analgesics 3.3

Most common drug mentions, 2004

Source: Hing, E. et al. National Ambulatory Medical Care Survey: 2004 Summary.

Advance data from vital and health statistics; no. 374. Hyattsville, Maryland: National

Center for Health Statistics. 2006.

Drug Mentions: 1990 vs. 2001

1990 Rank 2001

Antimicrobial agents 1 Antidepressants

Cardiovascular-renal drugs 2 NSAIDs

Respiratory tract drugs 3 Antiasthmatics or bronchodilators

Drugs used for relief of pain 4 Antihypertensive agents

Hormones and related agents 5 Hyperlipidemia

Psychopharmacologic 6 Antihistamines

Dermatologic 7 Acid or peptic disorders

Gastrointestinal agents 8 Antiarthritics

Ophthalmics 9 Blood glucose regulators

Metabolic and nutrient 10 Non-narcotic analgesics

Immunologics 11 Antipyretics

Neurologic s 12 ACE inhibitors

Hematologics 13 Narcotic Analgesics

Other and unclassified 14 Vitamins or minerals

Top 5 Drug Mentions: 1992 vs. 2003

1992 Rank 2003

Amoxicillin 1 Lipitor

Amoxil 2 Aspirin

Lasix 3 Lasix

Ceclor 4 Synthroid

Zantac 5 Zoloft

Change in percent of drug mentions, 1992 and 2001

Source: Cherry DK, et al. National Ambulatory Medical Care Survey: 2001 Summary.

Advance data from vital and health statistics; no. 337. Hyattsville, Maryland: National

Center for Health Statistics. 2003.

Table 5. Procedures; 1993 vs. 1998

1993 Rank 1998

Pap smear 1 Local excision of tissue of skin…

Electrocardiogram 2 Eye examination

Other nonoperative examinations 3 Vital capacity determination

Eye examination 4 Fetal monitoring

Routine chest x ray 5 General physical examination

Local excision of tissue of skin… 6 Other cardiovascular stress test

Microscopic exam of specimen 7 Biopsy of skin and subcut. tissue

Other individual psychotherapy 8 Other microscopic examination

Tonometry 9 Neurologic examination

Limited eye examination 10 Irrigation of ear

Other mammography 11 Fundus photography

Other physical therapy 12 Colonoscopy

General physical examination 13 Attention to wound

Gynecological examination 14 Fitting and dispensing of spectacles

15

18

Removal of other therapeutic device

Closed biopsy of uterus

Summary

1. The Medicare PPS stimulated rapid growth of ambulatory care programs.

2. Indian Health Services as the model for pharmacist as a primary care provider

3. Pharmacist-managed clinics4. Ambulatory practice overview with NAMCS

1. Complex drug therapy and diagnostic agents over time 2. Increasing trend of ambulatory surgery

5. Levels of emergency medical care