Sustainable Solutions Report: A Focus on Managing Complex Chronic Diseases

TABLE OF CONTENTS
Foreword 2 About the Shoppers Drug Mart Sustainable Solutions Report 4 General Practitioners Perceptions: Key Findings 5 Canadian Public Perceptions: Key Findings 8 Canadian Public Perceptions: Other Research Highlights 9 Recommendations 10 About Shoppers Drug Mart Corporation 13 About Arthritis Consumer Experts 13 About Arthritis Research Centre of Canada 13 References 14

01
S H O P P E R S D R U G M A R T S U S T A I N A B L E S O L U T I O N S R E P O R T: A F O C U S O N M A N A G I N G C O M P L E X C H R O N I C D I S E A S E S

Foreword

The increasing prevalence of complex chronic diseases is becoming one of the most important health issues in the 21st century. These diseases have a significant impact on Canadians ability to work and lead active lives. For that reason, the federal government has identified chronic disease prevention and management as a key priority. Chronic diseases include arthritis (affecting 4.4 million Canadians in 2012), hypertension (5.1 million), diabetes (1.9 million), asthma (2.4 million), and chronic obstructive pulmonary disease (806,592).i Overall, chronic conditions affect 37% of Canadians, and cause 70% of mortalities.ii Risk factors include some that cant be helped, like age and genetics, and others that are more controllable, like diet, exercise, and tobacco or excessive alcohol use. Not only are chronic diseases a concern for their impact on the health of Canadians, but they are also a substantial financial burden on the health care system. In 2011, the medical costs associated with chronic diseases were estimated at $42 billion, or 21% of total health care spending.iii Whats worse is that figure is expected to climb to $53 billion by 2015.iv These rising costs are unsustainable and solutions are needed now. Pharmacists are uniquely positioned to help government achieve their goals and be part of the solution by reducing health care expenses, while also improving patient care. This is true for the health care system as a whole, but particularly in the area of chronic disease management. For example, due to the complexity of some drug therapies for chronic care, many patients do not take their medication as prescribed. In fact, medication non-adherence results in 5% of hospital admissions, 5% of physician visits annually, and contributes $4 billion to health care costs each year.v If pharmacists were permitted to use their judgement in adjusting dosages and writing prescription renewals for specific drug classes, they could help ensure patients stay on track with their medication regimes. Important measures like this were outlined in a plan entitled, 9,000 Points of Care: Improving Access to Affordable Healthcare, released by Canadas broader pharmacy community. That plan estimated between $1.4 and $1.9 billion would be saved over three years by expanding the role of pharmacists in managing chronic diseases.vi It is also estimated that 1.3 million emergency room visits and 500,000 hospitalizations could be avoided, freeing up to 6.3 million hours of physician time.vii The following Sustainable Solutions Report outlines the results of a study of Canadian general practitioners (GPs) and their views on expanding the role of pharmacists in relation to chronic diseases and overall. It demonstrates the wider health care community supports pharmacists playing a more active role in primary care. For example, 88% of physicians say they would be open to having more support from other health care professionals to help manage care for their patients with chronic conditions. Four in five physicians (80%) agree pharmacists can play an important role in helping patients with chronic conditions manage their health. The Report also shows Canadians as a whole are open to using pharmacists expertise in an expanded way.

02
S H O P P E R S D R U G M A R T S U S T A I N A B L E S O L U T I O N S R E P O R T: A F O C U S O N M A N A G I N G C O M P L E X C H R O N I C D I S E A S E S

Foreword

The vast majority of Canadians (94%) agree pharmacists can play an important role in helping people with chronic conditions manage their health. Four in five Canadians (80%) agree they would speak with a pharmacist to help them manage their chronic condition if they had one.
Change needs to happen now in order for our health care system to remain sustainable for generations to come. Pharmacists want to be part of the solution. The report concludes with a set of recommended practical solutions that will not only save the health care system billions of dollars, but most importantly improve the care for the millions of Canadians managing complex chronic conditions like arthritis, diabetes and hypertension.

These recommendations include:

1.
Enable pharmacists to develop and manage patient care plans. This would involve one-on-one annual or semi-annual meetings with pharmacists who can proactively follow up to monitor health conditions and remind patients to adhere to and refill their prescriptions. An example of this type of program is the Shoppers Drug Mart Arthritis Screening, developed in partnership with Arthritis Consumer Experts (ACE) and the Arthritis Research Centre of Canada (ARC). The screening includes a joint exam and questionnaire which can help detect the disease early. It also helps Canadians with arthritis work with a pharmacist to monitor their symptoms and medication over time to prevent the disease from worsening.

2.
Where appropriate, allow pharmacists to make prescription renewals and adaptations. This would help ensure patients stay on track with their medication regimens.

3.
Consult the pharmacy community now to improve electronic infrastructure and information-sharing between pharmacists and physicians. An electronic infrastructure is already being developed, but the pharmacy community can provide valuable insights on what is needed and what improvements can be made. We hope these recommendations incite discussion and action among key stakeholders and government officials.

Domenic Pilla

President and CEO, Shoppers Drug Mart

Cheryl L. Koehn

Founder and President, Arthritis Consumer Experts

Dr. John Esdaile

Scientific Director, Arthritis Research Centre of Canada

03
S H O P P E R S D R U G M A R T S U S T A I N A B L E S O L U T I O N S R E P O R T: A F O C U S O N M A N A G I N G C O M P L E X C H R O N I C D I S E A S E S

About the Shoppers Drug Mart Sustainable Solutions Report

The Sustainable Solutions Report: A Focus on Managing Complex Chronic Diseases is the first in a series of reports that will be issued by Shoppers Drug Mart exploring different ways pharmacists can contribute to reforming our health care system through cost-cutting, wait times reduction, improving patient care and generally making Canadians healthier.
As part of the report, research was conducted with Canadian family physicians and the general public to find out their views on expanding the role of pharmacists in the health care system and the impact it could have on chronic disease care. The goal of this research is to demonstrate support from the wider health care community and the public for pharmacy solutions to health care reform.

The physician research was conducted by Environics Research Group with 204 general practitioners and completed online from May 14 to May 27, 2013. A probability sample of the same size would yield a margin of error is +/- 6.9 points, 19 times out of 20. The general public research was conducted by Vision Critical with 1,505 Canadians 18 years of age or older and completed online from July 16 to 17, 2013. A probability sample of the same size would yield a margin of error is +/- 2.53% points, 19 times out of 20.

04
S H O P P E R S D R U G M A R T S U S T A I N A B L E S O L U T I O N S R E P O R T: A F O C U S O N M A N A G I N G C O M P L E X C H R O N I C D I S E A S E S

General Practitioners Perceptions: Key Findings

Family physicians welcome support from other health care professionals in providing care to time-intensive patients with chronic conditions.
 The overwhelming majority of general practitioners (93%) agree that counselling patients with chronic conditions like arthritis, diabetes and hypertension is time consuming.  Four in five family doctors (80%) admit they dont have as much time as theyd like to counsel their patients with chronic conditions.  Eighty-eight per cent of physicians say they would be open to having more support from other health care professionals to help manage care for their patients with chronic conditions like arthritis, diabetes, or hypertension.

05
S H O P P E R S D R U G M A R T S U S T A I N A B L E S O L U T I O N S R E P O R T: A F O C U S O N M A N A G I N G C O M P L E X C H R O N I C D I S E A S E S

General Practitioners Perceptions: Key Findings

Physicians and pharmacists currently work together in a number of ways to provide care for patients with chronic conditions.
 Four in five physicians (80%) agree pharmacists can play an important role in helping patients with chronic conditions manage their health.  Three quarters of family doctors (73%) say they frequently interact with pharmacists regarding patients with chronic conditions like arthritis, diabetes or hypertension.  Some of the most common reasons for those interactions include pharmacists contacting a physician for refills of medications for patients who require no change in script (60%) and pharmacists requesting a dosage change for a medication thats been prescribed (46%).

How do you typically interact with pharmacists regarding patients with chronic conditions like arthritis, diabetes or hypertension?
Pharmacist contacts you for refills of medications for patients who require no change in script Pharmacist contacts you regarding adverse drug reactions Pharmacist contacts you regarding problems related to side-effects that patients have with medications Pharmacist contacts you to request a dosage change for a medication youve prescribed Pharmacist contacts you to request switching your prescription to a similar medication that is generic Pharmacist contacts you to request switching your prescription to a similar medication that is not generic Pharmacist contacts you regarding patients symptoms
21% 30% 38% 46%

60%

58%

58%

06
S H O P P E R S D R U G M A R T S U S T A I N A B L E S O L U T I O N S R E P O R T: A F O C U S O N M A N A G I N G C O M P L E X C H R O N I C D I S E A S E S

60

General Practitioners Perceptions: Key Findings

General practitioners see pharmacists as valuable contributors to the care of patients with chronic conditions and would welcome pharmacists playing a bigger role.
 When asked to characterize their interactions with pharmacists regarding the treatment of patients with chronic conditions, more than half of physicians (54%) say they value pharmacists contributions.  Ninety per cent of physicians say they find the information they receive from pharmacists useful regarding patients with chronic conditions.

How would you describe the information you generally receive from pharmacists regarding patients with chronic conditions like arthritis, diabetes or hypertension?

1% 9% 14%
Always useful Usually useful Occasionally useful

35% 41%

Rarely useful Dont know/ Prefer not to answer

Physicians acknowledge expanding the role of pharmacists will benefit patients in the management of their chronic conditions.
 Fifty-two per cent say pharmacists can assist doctors with upkeep of patient records by giving them access to updated medication lists, including patients over-the-counter and natural health product information. Two in five (40%) say patients will get quicker access to some services.
Don't know/ Prefer not to answer

 Physicians agree that patients will benefit if pharmacists start offering services such as: useful counselling Never on medication management (88%), emergency prescription refills (87%), counselling on lifestyle management (87%), and changing the dosage of a drug (27%).
Always useful 14% Usually useful 41% Occasionally useful 35% Rarely useful 9% Never useful Don't know/ SHOPPERS DRUG MART Prefer not to answer 1%

Rarely useful Occasionally useful

07
S U S T A I N A B L E S O L U T I O N S R E P O R T: A F O C U S O N M A N A G I N G C O M P L E X C H R O N I C D I S E A S E S

Usually useful Always useful

Canadian Public Perceptions: Key Findings

Canadians want pharmacists to help them better manage their chronic conditions and would make use of their services.
 The vast majority of Canadians (94%) agree pharmacists can play an important role in helping people with chronic conditions manage their health.  Four in five Canadians (80%) agree they would speak with a pharmacist to help them manage their chronic condition if they had one.  Eighty-seven per cent would like pharmacists to help make sure they take their medication as prescribed. A further 96% agree they would like pharmacists to help ensure their prescriptions dont run out when they need them.

Assuming the following services were available in your province, would you choose to go to a pharmacist for each of the services listed?
Emergency prescription refills Renewal/extension of ongoing prescription

61%

28%

7% 2%2%

49%

27%

13%

6%

5%

Modify a prescription Have pharmacist assess risk for developing chronic conditions Advise on healthy lifestyle management Regular one-on-one pharmacist meetings to review medications and discuss health issues

25%

29%

22%

15%

9%

18%

27%

26%

20%

9%

20%

32%

29%

15%

4%

26%

33%

23%

12%

6%

Strongly Agree

Agree

Somewhat Agree

Somewhat Disagree

Strongly Disagree

08
S H O P P E R S D R U G M A R T S U S T A I N A B L E S O L U T I O N S R E P O R T: A F O C U S O N M A N A G I N G C O M P L E X C H R O N I C D I S E A S E S

Canadian Public Perceptions: Other Research Highlights

Other recent research reports also show the general public is supportive of pharmacists playing an expanded role in the Canadian health care system. Some recent research highlights include:
Canadians support an expanded role for pharmacists in primary care, particularly in regard to helping them manage chronic conditions like arthritis, hypertension and diabetes.
 The Canadian Association of Chain Drug Stores (CACDS) reported more than four in five Canadians (81%) said pharmacists should have an expanded role in health care delivery.viii  A recent study by the Canadian Pharmacists Association (CPhA) found 53% of older Canadians said they would consult with a pharmacist about managing chronic illnesses like diabetes, cardiovascular disease or asthma. It also found 40% of Canadians said they would see or consult a pharmacist for the renewal/extension of an ongoing prescription.

09
S H O P P E R S D R U G M A R T S U S T A I N A B L E S O L U T I O N S R E P O R T: A F O C U S O N M A N A G I N G C O M P L E X C H R O N I C D I S E A S E S

Recommendations

Health care costs and chronic disease cases are on the rise, and on track to only get worse in the near future. As a result, measures must be taken now to help ease the burden on the system. Chronic diseases have been identified as a government priority, and pharmacists are uniquely positioned to be part of the solution. Expanding the role of pharmacists is a way to not only cut health care costs, but also improve patient outcomes. Below are three implementable solutions that if taken will save the health care system between $1.4 and $1.9 billion over three years.ix It is also projected these steps could prevent 1.3 million ER visits and 500,000 hospitalizations, while freeing up to 6.3 million hours of physician time.x 1.  Develop and Manage Care Plans: Pharmacists can play an important role in educating and empowering patients to better manage their chronic conditions. This comprehensive consultative approach would involve annual or semi-annual meetings to establish and track disease management plans. These consultations could include providing patients with lifestyle management tips, one-on-one or group counselling, and information on symptom and side effect-management. Pharmacists can also proactively follow-up with patients to monitor health conditions and regularly remind patients to adhere to and refill their medications as prescribed by their physicians.

10
S H O P P E R S D R U G M A R T S U S T A I N A B L E S O L U T I O N S R E P O R T: A F O C U S O N M A N A G I N G C O M P L E X C H R O N I C D I S E A S E S

Recommendations

 Many community pharmacies already provide patient care plans, however they are not offered consistently across the country. In order to make this possible, regulatory or policy changes must be made to enable pharmacists to develop and manage these care plans, and also ensure compensation structures are in place where they are not already. Shoppers Drug Mart currently offers a number of these types of support programs for those living with chronic illnesses. These programs aim to ease the burden on physicians and emergency rooms by helping to better manage chronic conditions, and there is an opportunity to develop more programs and make them more widely available. Current examples are outlined below. Heart Health

 High blood pressure affects about 1 in 5 Canadians and many may not even know it.xi In fact, an estimated 17% of Canadians have undiagnosed high blood pressure and almost 1 in 3 people with hypertension have uncontrolled blood pressure.xii Recognizing this problem, Shoppers Drug introduced a unique online tool, the Heart Age Calculator, designed to help Canadians determine their heart age and take corrective action to reduce their risk of heart disease and stroke. The tool was created in conjunction with the research team of Dr. Steven Grover, director of the McGill Cardiovascular Health Improvement Program (CHIP) at McGill University Health Center in Montral, and is the only scientifically validated online tool available that provides a personalized heart age and cardiovascular risk profile as recommended by the Canadian Cardiovascular Society guidelines.  Since the launch of the calculator, close to 120,000 Canadians have completed the questionnaire and it was found that: 30% of those who completed had higher cardiovascular age than their actual age 36% didnt know their blood pressure 89% didnt know their cholesterol 13% had missed blood pressure or diabetes medications

 Equipped with this knowledge, Shoppers Drug Mart pharmacists have an opportunity to intervene and educate the patient about the importance of monitoring their blood pressure, adhering to their medication and making important lifestyle changes to improve their overall health to avoid the risk of heart attack and stroke. Arthritis  It is estimated that one in six Canadians aged 15 years and older are living with arthritis and that number is expected to rise to one in five by 2031. The prevalence of arthritis in Canada has a tremendous impact, which translates into lost productivity, absenteeism and increased health care spending, an estimated total cost of $33 billion annually.

11
S H O P P E R S D R U G M A R T S U S T A I N A B L E S O L U T I O N S R E P O R T: A F O C U S O N M A N A G I N G C O M P L E X C H R O N I C D I S E A S E S

Recommendations

Studies conducted by the Arthritis Research Centre (ARC) show pharmacists can play an integral role in  the identification of osteoarthritis. In conjunction with the Arthritis Consumer Experts (ACE) and ARC, Shoppers Drug Mart developed an arthritis screening for Canadians. Together with a Shoppers Drug Mart pharmacist, the patient is guided through an exam and questionnaire to assess their risk of arthritis. If more information or treatment is needed, the pharmacist can then refer the patient to the most appropriate health care provider (e.g., doctor, physiotherapist, occupational therapist or dietician). The screening can be used to help monitor the disease and symptoms over time to ensure the medication and therapy are appropriate for the patient. The program launched August 10, 2013.

2.  Prescription Renewals and Adaptations: Pharmacists should be empowered to provide prescription renewals and adaptations, including dosage changes for specific drug classes. Alberta has permitted pharmacist prescription renewals since 2007, and British Columbia made the move in 2009. The result is that up to two per cent of renewals are performed by pharmacists, which reduces the number of physician visits. Overall, there is a great need for prescription renewal and adaptation services to be offered to Canadians in all provinces/territories to help pharmacists ensure their patients stay on track with their medication regimens, and to help lighten physicians workload. 3.  Facilitate Patient Updates Through Electronic Communications: Protocols must be defined in order to facilitate electronic communications between physicians and pharmacists regarding patients health. Setting up this type of system will allow pharmacists to send regular update reports to physicians about a patients symptoms, concerns or questions. The physician in turn will be more up-to-date on a patients file and be better equipped to decide whether the patients chronic disease management plan needs to be adjusted.

Its clear, government investment in pharmacy-supported solutions like these makes good financial sense and even better health sense. We need change now to help ensure the sustainability of our health care system for Canadians of today and future generations. The pharmacy community has listened by providing these implementable solutions. Now we need the help to make it happen.

12
S H O P P E R S D R U G M A R T S U S T A I N A B L E S O L U T I O N S R E P O R T: A F O C U S O N M A N A G I N G C O M P L E X C H R O N I C D I S E A S E S

About Shoppers Drug Mart Corporation

Shoppers Drug Mart Corporation is one of the most recognized and trusted names in Canadian retailing. The Company is the licensor of full-service retail drug stores operating under the name Shoppers Drug Mart (Pharmaprix in Qubec). With more than 1,242 Shoppers Drug Mart and Pharmaprix stores operating in prime locations in each province and two territories, the Company is one of the most convenient retailers in Canada. The Company also licenses or owns 57 medical clinic pharmacies operating under the name Shoppers Simply Pharmacy (Pharmaprix Simplement Sant in Qubec) and six luxury beauty destinations operating as Murale. As well, the Company owns and operates 62 Shoppers Home Health Care stores, making it the largest Canadian retailer of home health care products and services. In addition to its retail store network, the Company owns Shoppers Drug Mart Specialty Health Network Inc., a provider of specialty drug distribution, pharmacy and comprehensive patient support services, and MediSystem Technologies Inc., a provider of pharmaceutical products and services to long-term care facilities.

About Arthritis Consumer Experts

Arthritis Consumer Experts (ACE) provides science-based information, education and support programs to people with arthritisto help them take control of their disease and improve their quality of life. ACE actively advocates on arthritis health issues through ACEs JointHealth family of programs and the annual National Arthritis Awareness Program. Please visit joint http://jointhealth.org, join us on Facebook.com/arthritisbroadcastnetwork, follow us on Twitter @ArthritisNetwrk or download our app http://bit.ly/GetArthritisIDPRO.

About Arthritis Research Centre of Canada

The Arthritis Research Centre of Canada (ARC) is an international leader in medical research on Canadas most debilitating chronic disease. ARC conducts consumer-driven clinical research to help reduce the burden of arthritis, and give people with arthritis better, more timely, and cost-effective solutions for living with their disease. With research centres in British Columbia, Alberta and Quebec, ARCs research is making a critical difference in arthritis diagnosis, prognosis, prevention, care outcomes and quality of life issues for millions of arthritis patients. http://www.arthritisresearch.ca.

13
S H O P P E R S D R U G M A R T S U S T A I N A B L E S O L U T I O N S R E P O R T: A F O C U S O N M A N A G I N G C O M P L E X C H R O N I C D I S E A S E S

References

 tatistics Canada. Available online at: http://www.statcan.gc.ca/tables-tableaux/sum-som/l01/ind01/l3_2966_1887-eng.htm?hili_ S health52.  000 Points of Care: Improving Access to Affordable Healthcare, April 2013, pg. 19. Available online at: 9 http://9000pointsofcare.ca/wp-content/uploads/The-Plan.pdf.

ii

iii

9000 Points of Care: Improving Access to Affordable Healthcare, April 2013, pg. 19. Available online at: http://9000pointsofcare.ca/wp-content/uploads/The-Plan.pdf.
iv

 9000 Points of Care: Improving Access to Affordable Healthcare, April 2013, pg. 19. Available online at: http://9000pointsofcare.ca/wp-content/uploads/The-Plan.pdf.  9000 Points of Care: Improving Access to Affordable Healthcare, April 2013, pg. 19. Available online at: http://9000pointsofcare.ca/wp-content/uploads/The-Plan.pdf.  9000 Points of Care: Improving Access to Affordable Healthcare, April 2013, pg. 20. Available online at: http://9000pointsofcare.ca/wp-content/uploads/The-Plan.pdf.  9000 Points of Care: Improving Access to Affordable Healthcare, April 2013, pg. 5. Available online at: http://9000pointsofcare.ca/wp-content/uploads/The-Plan.pdf. Community Pharmacy Survey, Resonant Strategy + Messages study conducted on behalf of the Canadian Association of Chain Drug Stores, the Canadian Generic Pharmaceutical Association and the Canadian Association for Pharmacy Distribution Management, April 2013. 9000 Points of Care: Improving Access to Affordable Healthcare, April 2013, pg. 20. Available online at: http://9000pointsofcare.ca/wp-content/uploads/The-Plan.pdf. 9000 Points of Care: Improving Access to Affordable Healthcare, April 2013, pg. 5. Available online at: http://9000pointsofcare.ca/wp-content/uploads/The-Plan.pdf. Heart & Stroke Foundation. High blood pressure. http://www.heartandstroke.com/site/c.ikIQLcMWJtE/b.3484023/, accessed October 11, 2011.

vi

vii

viii 

ix 

x 

xi 

14
S H O P P E R S D R U G M A R T S U S T A I N A B L E S O L U T I O N S R E P O R T: A F O C U S O N M A N A G I N G C O M P L E X C H R O N I C D I S E A S E S