Abstract

Qatar is the world’s highest per capita income non-OECD country as well as having the highest per capita health expenditure in the region. The Qatari pharmaceutical market reached a value of USD 559 million in 2016. There is a difference in pricing of dispensed medicines for Qataris and non-Qataris at the Hamad Medical Corporation health institutions. The development of the pharmaceutical market is shaped by the decision of the Ministry of Public Health (MoPH) formerly known as Supreme Council of Health (SCH) to abolish government controls over the pricing of medicines and to allow more importing agents and suppliers in the country and has resulted in the adoption of an open market system.

The retail prices of medicines remain among the highest in the region. There is no policy on the bioequivalence of generic medicines, but the government is promoting the use of generic medicines despite the extensive use of branded medicines in Qatar’s healthcare facilities. A high share of imported and branded medicines, which are trusted and preferred by prescribers and consumers, has increased the Qatari government’s healthcare spending. SCH’s attempt to remove price controls had affected the affordability of medicines as the prices of some drugs had increased and were inconsistent across facilities. The government has had to implement price controls, although it abstained from explicitly fixing prices.

Keywords: Generic Medicines, Medicines, Medicines Policy, Pharmaceutical Sector, Pharmaceutical Pricing, Qatar

Introduction

Rising pharmaceutical expenditures have impacted healthcare systems across most countries worldwide. This phenomenon affects country’s ability to provide affordable, equitable and good quality care to the society [1]. One of the most important strategies to overcome these challenges should be through the implementation of acceptable, comprehensive and feasible medicines policy.

Qatar desires to manage and develop an integrated healthcare system according to world-class standards in order to improve the health of Qatar’s population. The plans are to improve the health and extend the life expectancy of its population and to meet the requirements of present and future generations. Overall healthcare services are intended to be accessible and affordable to the entire population. The healthcare system is available to all, regardless of nationality [2]. The population of Qatar is estimated to be 2.59 million in 2016, approximately 80% being expatriates [3]. In 2015, life expectancy at birth was 78 years [4,5]. Qatar is the world’s highest per capita income non-OECD country. In 2014, GDP per capita (PPP) is estimated at USD 140, 649 vs USD 134, 117 in 2011 [6]. Health expenditure excluding the private sector accounted for 1.9% of GDP in 2015 [7].

The Ministry of Public Health (MoPH), previously known as the Supreme Council of Health (SCH), is responsible and committed to providing quality and effective healthcare services. It oversees the services delivered by public institutions such as Hamad Medical Corporation, Primary Health Care Corporation and the private sector to ensure compliance with standards and achievement of performance targets. It develops and regulates policies, and also oversees public health programs and environmental and public safety promotion [8].

The pharmaceutical sector is vital to supporting the achievement of high standard healthcare services. There is lack of information and comprehensive assessment of the pharmaceutical sector in Qatar especially in relation to medicine pricing policy. Health Action International (HAI) in collaboration with World Health Organization (WHO) have conducted studies in many countries on medicines prices but there is limited data on Qatar. It is appropriate to study the current status of the pharmaceutical sector before evaluating the price of medicines.Thus, this paper aims to assess the present pharmaceutical sector and its medicines pricing policy.

Methodology

A survey using secondary data was conducted to achieve the above study objective. Data was gathered from ministries, healthcare institutions, corporate and private organizations, international non-profit organizations and media. Materials used for gathering information and data are peer-reviewed articles, policy documents, national annual statistics, private sector and organization publications, daily newspaper and institutions websites. Information and data are analyzed descriptively as frequency and percentages, and presented in tabular form.

Findings and discussion

Healthcare system

Health service performance and diseases: Despite the increased life expectancy of the Qatari population, many people suffer from non-communicable diseases (NCDs) such as diabetes, cancer and heart disease. Qatar has committed to combat the widespread prevalence of NCDs and the morbidity associated with these diseases [9]. Table 1 demonstrates that the health services and personnel have improved over the years. There are 14 public, private and semi-public hospitals, 22 health centers, and 317 private, individual and multiple clinics. Hospital beds per 1,000 people have increased to 1.2 beds in 2014. The total number of doctors has increased from 3.11 doctors per 1,000 people in 2006 to 4.03 in 2010 [9-11].

pending

Ethical Considerations

Cwm Taf UHB approved this research as a ‘service evaluation’ and ethical approval from the Cardiff School of Pharmacy and Pharmaceutical Sciences Research Ethics Committee was obtained prior to the study commencing.

Data Collection

Data collection using paper intervention forms for the Dom- MURs database was undertaken by pharmacists as they made interventions. During Dom-MURs, pharmacists were required to document all interventions made, even where no actions were identified, and submit a copy of the action plan to the UHB following the review. In collaboration with the Cwm Taf UHB lead investigators, a database with entries from the original MUR documentation completed by pharmacists during Dom- MURs between December 2012-March 2014 was obtained. The database was reviewed and three main identities were established – issues, outcomes and medication.

Validation Stage

Categories were assigned to issues and outcomes independently. Regular group discussions to ensure consistency increased the validity of data. The main categories used to assign issues are shown in (Table 1) the categories used to assign outcomes are shown in (Table 2). Medications involved in issues were classified using the chapters of the British National Formulary (BNF) [25].

Data Input

Qualitative data collected from original MUR documentation was input into a Microsoft Excel® database by the Cwm Taf UHB lead investigators prior to the study commencing. The data included: a reference number for each patient, the issue/s recorded by the pharmacist, whether the issue was to be considered by the GP, pharmacist, patient or ‘not specified’ and the outcomes.

Some rows (i.e. entries) on the original database contained multiple issues or outcomes and could be assigned to more than one category. Patients often had multiple entries in the database. Some patients had no issues recorded during their reviews, whereas some patients had issues recorded as well as appropriate checks (compliance etc.) documented by the pharmacist with no further issues. Tally charts were produced to display the assignment of issues, outcomes and medication to categories (Appendix 6).

To aid descriptive statistical analysis, a second Microsoft Excel® spreadsheet was produced with the reference number of the patient, the number of issues per patient, the number of outcomes per patient, the categories of issues identified (as a number e.g. 1.1.1.) and the categories of outcomes (as a number e.g. 2.1.1.). BNF chapters (as a number e.g. 2) and BNF classes (in words e.g. Statins) were assigned to issues where medication was named.

Data was also input into GraphPad Prism®. This data included the issues identified per category and whether pharmacists could resolve the issues within those categories themselves or not (1=the pharmacist resolved the issue themselves, 2=the pharmacist did not resolve the issue themselves).

Analysis

Microsoft Excel® was used to calculate means, standard deviations and modes for the number of issues and outcomes per patient, as well as percentages of issue and outcome categories. Excel® was also used to analyze medication data, including a ranked list of medication categorized by BNF chapter. Graphs and charts displaying data were produced using Excel®. GraphPad Prism® was used to perform a one-way ANOVA with Tukey’s post-hoc test to check for statistically significant differences in the proportion of issues within different categories that pharmacists were able to resolve themselves.

Results

Issues per patient

Data from Dom-MURs with 194 patients was included within the database. (Figure 1) shows the number of issues identified per patient. Thirteen patients (6.7%) had no issues identified during their review. The remaining 181 patients had at least one issue identified. The mean number of issues identified per patient was 1.96 (SD 1.41). The most common number of issues identified per patient was one issue (39.69%, n=77). One patient had 10 issues, which was the largest number of issues identified per patient. Of the 13 patients who had no issues identified at all during their review, 4 were documented to have had appropriate checks carried out during the MUR (adherence etc.). The remaining 9 had no checks documented by the pharmacist hence it was impossible to determine whether the pharmacist had checked the patient’s adherence, understanding of medicines etc.

Issue categories identified

The database contained a total of 380 issues, with 11 categories of issues identified. (Figure 2) shows the proportion of issue categories identified in Dom-MURs. The three most commonly identified issues within the Dom-MURs were related to ‘Patient Adherence’ (29%, n=110), ‘Patient Education/ Monitoring’ (21%, n=79) and ‘Medication Excess in Home’ (12%, n=47).

A further 28 entries fell into the category ‘1.12. No Issues’. Thirteen of these related to patients who had no issues identified during their MUR, as previously stated. The remaining 15 entries related to patients who did have other issues recorded, with ‘no issue’ referring to respective checks also documented (adherence etc.).

BNF classification of medication

Of the total issues, 65.79% (n=250) had at least one named medication related. Some issues had multiple medications named. The total number of named medications related to issues was 283. (Table 3) shows a ranked list of the most common types of named medicines, categorized by BNF chapter.

Medication could only be included in figures if the name of the medication was specifically stated. For example, ‘inhalers’, whilst referring to a medicine, could not be classified. Cardiovascular and respiratory medications were most commonly related to issues. Antiplatelet drugs and statins were the most common cardiovascular medications. The most common issue related to both antiplatelet drugs and statins was non-adherence (46.2%, n=6 and 69.2%, n=9 respectively). Inhaled corticosteroids were the most common respiratory medication. The most common issue related to inhale corticosteroids was patient education: inhaler technique (40.7%, n=11).

Outcomes

The database contained a total of 383 outcomes documented by pharmacists. Some issues had more than one outcome documented. (Figure 3) shows the proportion of outcome types documented. The mean number of outcomes per patient was 1.97 (SD±1.48). Fifty-seven percent (n=220) of outcomes were pharmacist-resolved, either during Dom-MURs or back in the pharmacy. Thirty-two percent (n=122) of outcomes involved pharmacists contacting the GP surgery i.e. they could not resolve these issues themselves. (Figure 4) shows a breakdown of reasons for pharmacists contacting the GP surgery.

Common reasons pharmacists contacted the GP surgery included: to remove an item from repeat (18.03%, n=22)), to request the GP to review the patient/ medication (17.21%, n=21), to recommend changing formulation/ flavour (15.6%, n=19), to amend monthly medication quantity (9.02%, n=11) and to check patient’s notes (11.5% n=14).A further 11% (n=41) of outcomes were patient-led, where pharmacists recommended that patients make appointments with healthcare professionals but did not do this on their behalf. There were 7 issues identified by pharmacists with no definite outcomes documented hence it was unclear what, if anything, had been recommended to resolve these issues. Figure 5 shows a comparison of outcome types between categories of issues, taking into account the 7 issues with no definite outcomes recorded.

The proportion of pharmacist-resolved outcomes was greatest in ‘1.11. Medication Excess in Home’. The proportion of outcomes where pharmacists contacted the GP surgery was greatest in ‘1.10. Communication/ Clarification with GP Needed’. All outcomes within ‘1.8. Assessment required’ were patient-led, as pharmacists recommended all patients within this category make appointments with an optician.

Statistical analysis

To check whether there were statistically significant differences in the types of issues that pharmacists were able to resolve themselves, p-values were calculated using a one-way ANOVA with Tukey’s post-hoc test. The category ‘1.8. Assessment required’ was omitted as it contained a low number of issues (n=4). One-way ANOVA showed there was a highly significant difference in the pharmacists’ ability to resolve different types of issues overall (p<0.0001).

To compare between different categories of issues, Tukey’s post-hoc test was utilized. Three groups were found to be statistically significant (p<0.05) to the rest: Issues with Patient’s Condition, Communication/Clarification with GP needed and Medication Excess in Home.

In more detail significant differences were found between ‘1.6. Issues with Patient’s Condition’ and ‘1.1. Lifestyle’; ‘1.2. Patient Education/ Monitoring’, ‘1.4. Patient Adherence’’ AND ‘1.11. Medication Excess in Home’; ‘1.10. Communication/ Clarification with GP Needed’ and ‘1.1. Lifestyle’; 1.2. ‘Patient Education/ Monitoring’, ‘1.4. Patient Adherence’’ AND ‘1.11. Medication Excess in Home’; ‘1.10. Communication/ Clarification with GP needed’ and ‘1.3. Medication Assistance Required’ AND ‘1.5. Issues with Repeat Medication/ Prescription’; ‘1.11. Medication Excess in Home’ and ‘1.4. Patient Adherence’ AND ‘1.5. Issues with Repeat Medication/ Prescription’.

Statistical analysis highlights there were types of issues that pharmacists were less likely to resolve themselves, in particular issues in ‘1.10. Communication/ Clarification with GP Needed’ and ‘1.6. Issues with Patient’s Condition’.

Discussion

Few domiciliary MUR services are commissioned in the UK, with little published data regarding the types of issues identified and interventions made. This is the first study to identify the types of issues and interventions carried out by pharmacists as part of a Dom-MUR service. Issues and outcomes were categorised and quantified, with medication classified according to the BNF.

The vast majority of Dom-MURs identified at least one issue. The mean number of outcomes per Dom-MUR was 1.97, approximately three times higher than the mean number of outcomes per pharmacy-based MUR in the UHB (E. Williams, personal communication). This suggests that the service targets appropriate patients who are in most need of medication reviews, which is the predominant rationale for commissioning this service. This may have been aided by pharmacists being able to see how patients manage their medication in their homes. Patients may also have felt more comfortable being reviewed in their own homes, resulting in a more open conversation hence more issues being identified.

Most research regarding MURs focus on the process rather than content and outcomes of reviews. The three main issues identified tend to be the focus of MURs. Twenty-nine percent of issues were related to patient non-adherence with 59% resolved by pharmacists. It is unsurprising that non-adherence was the most common issue identified. As housebound patients tend to have less contact with healthcare professionals, there is less opportunity to encourage these patients to take their medications as prescribed hence domiciliary visits from pharmacists are potentially valuable. However, a Cochrane review on interventions to improve adherence identified little published evidence on what works best [26]. Although pharmacists identified and may have ‘resolved’ the issue by giving advice, this does not mean that patients’ long-term adherence has improved. Follow-up studies of these patients over time would indicate whether adherence issues have actually been resolved long-term.

Medication wastage is estimated to cost NHS Wales up to £50 million annually [27]. Eighty-six percent of medication excess issues identified were resolved by pharmacists which is important as intervening with medication excess helps reduce further wastage and NHS costs. This is likely to have been helped by pharmacists being able to see expired medicines and unused supplies unlike pharmacy-based MURs where patients often bring samples of what they can carry hence these issues can often go unnoticed [5].

Cardiovascular and respiratory medications were most commonly related to issues, similar to a larger pharmacy-based study of 1948 MURs which found that cardiovascular medications accounted for the largest number of medications needing action [11]. A large proportion of respiratory medication issues were related to inappropriate inhaler technique, all of which resulted in education by pharmacists during reviews which is important as inadequate technique leads to poor adherence and suboptimal therapy [28,29]. These medication groups are part of the targeted MUR eligibility criteria therefore the Dom-MUR service can potentially support the provision of targeted MURs.

A large proportion of issues, in particular regarding lifestyle, patient education and medication excess, were resolved by pharmacists themselves. However, there were issues that pharmacists were statistically less likely to resolve themselves, with 32% of outcomes involving pharmacists contacting GP surgeries. Reports in the literature comment that many GPs query the benefit of MURs, in particular the paperwork involved and the types of recommendations made by pharmacists [30]. A pharmacy-based MUR study found that a considerable number of recommendations were not subsequently auctioned by GPs [11]. Follow-up information of this kind was not available in this project. While contacting the GP is inevitable in certain situations, pharmacists should resolve as many issues as possible to relieve the burden on GP surgeries, with the Royal Pharmaceutical Society (RPS) stating:

“No GP should routinely be undertaking any activity which could, just as appropriately, be undertaken by an advanced practice nurse, a clinical pharmacist or an advanced practitioner paramedic” [31].

The role of the pharmacist is expanding, with increasing prevalence of pharmacists in GP surgeries and the Common Ailments Service introduced in Cwm Taf UHB to cut pressures on GPs [32]. Of the situations where pharmacists contacted the GP surgery, 11.5% were to check patients’ health records, for example to check indications of medication. NHS England has supported community pharmacies in gaining access to Summary Care Records (SCR), enabling pharmacists to support patients with better-informed care and reducing the need to contact GPs [33,34]. An evidence review from MURs published in 2010 found that the quality of recommendations made by pharmacists improves when pharmacists have more patient information [35]. It is hoped in the near future a similar set-up will be implemented for community pharmacists in Wales to access GP records, with the RPS stating:

“In the interest of safe and effective patient care, all pharmacists involved in an individual’s care should have appropriate read and write access to the Welsh GP record”. This may aid the Dom-MUR service, reducing the need for pharmacists to contact GP surgeries to check patients’ records. The RPS is also keen for pharmacists to fully utilize their expertise in supporting patients with long-term conditions, and encourage opportunities for pharmacists to become prescribers [31]. The 2016 Murray Review has called for a redesign of MURs, utilizing pharmacist independent prescribers (PIPs) to implement medicines optimization [36]. PIPs may be beneficial in developing the Dom-MUR service, with potential to further reduce the number of issues passed on to GPs. For example, 15.6% of reasons for contacting GPs were to amend medication formulation/ flavor, which could have been resolved by PIPs.

However, the potential of PIPs has not been exploited especially in the community sector. Limited funding and access to patient records are recognised as barriers [37], but access to the Welsh GP record and emphasis on pharmacists’ abilities to help with current pressures on GP surgeries may increase the prevalence of community pharmacist prescribing, potentially enhancing the Dom-MUR service. It is important to note however that PIPs should only prescribe within their competence in a therapeutic area. This may affect how patients are targeted for domiciliary visits in the UHB, with PIPs targeting patients who have clinical conditions within their therapeutic area.

Study limitations

This study relies on completeness of MUR documentation by pharmacists, who may have addressed issues during reviews which they failed to document. If so, this study would underestimate the overall number of issues identified. It is recognised in the literature that pharmacists may priorities issues to address in reviews, leaving less important issues for follow-up appointments [38].

The database, comprised of faithful transcriptions of original MUR documentation, was often vague. Some pharmacists were less thorough in their documentation, making categorization of issues difficult especially as many medications were not specifically named. Lack of uniformity between pharmacists in documenting MURs has been recognised in the literature. Categorization of issues introduced bias to the study due to their subjective nature. The vast majority of issues assigned to ‘1.10. Clarification/ Communication with GP Needed’ could not be resolved by pharmacists themselves due to the nature of the issues. These issues could not be assigned elsewhere, but it could be argued that this category is an outcome rather than an issue. This is a unique study hence a published classification system to analyzed Dom-MURs was not available. Classification systems to analyzed pharmacy-based MURs have been published [38], but it was deemed that utilizing them would lead to issues being assigned to inappropriate categories. Discontinuation of domiciliary services is common [19]. A similar domiciliary service was piloted and subsequently withdrawn in Abertawe Bro Morgannwg UHB due to logistical difficulties of pharmacists leaving the pharmacy to conduct domiciliary visits (Morris A. 2017. Personal communication). It would be critical to also gather the views of pharmacists undertaking the Dom-MUR service to identify any barriers they perceive in delivering the service.

Conclusion

The Cwm Taf Dom-MUR service targets appropriate patients in need of medication reviews and this study shows that the service has the potential to be of value in helping housebound patients benefit from their medicines. Future developments in community pharmacy, such as increasing prevalence of pharmacist independent prescribing and access to patients’ health records, may further the potential to utilize pharmacists’ expertise and reduce the burden on GP surgeries to resolve issues identified. The opinions of pharmacists who conduct the service still need to be explored to supplement quantitative data and provide a wider evaluation of the service.

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