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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 Investigación
Escuela 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 NOINSTITUCIONALIZADOS” (SHAPER, 1999)
– “CUIDADO A PACIENTES QUE VAN
VOLUNTARIAMENTE CAMINANDO A BUSCAR
SERVICIOS DE SALUD” (WILLIAMS, 1999)
PERSPECTIVA HISTÓRICA
• SOCIEDADES PRIMITIVAS • SOCIEDAD MODERNA
– MÉDICO BRUJO
– AUMENTO EN ESPECIALIZACIÓN
– MÉDICO DEL VECINDARIO – 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
Inpatient care
Research
Specialty clinics
Outpatient care

Increased role for
the primary care
practitioner
• VA medical centers
– Pharmacists in ambulatory care
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 services
1. 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. Shocktrauma 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 services
1. Hospital outpatient clinics
 Changes of approach
Centralized
Inpatient
pharmacy
Decentralized
Outpatient
pharmacy
 Pharmacist-managed clinics
• e.g., diabetes, lipid, or anti-coag clinics
• Improvement in patient compliance and
follow-up appointments
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
Corazón
5,031
Cáncer
4,898
Diabetes
2,569
Muertes
Infantiles
416
Matrimonios
23,650
Bajo peso
5,872
Defunciones
Divorcios
29,066
15,197
Madres
Adolescentes
9,299
Población
CV
1,532
Alzheimer
1,211
3,894,855
Muertes
fetales
537
Otras
13,894
Madres
solteras
28,320
Nacimientos
51,239
Un Día en Puerto Rico 2010
Corazón
14
Cáncer
13
Diabetes
7
Muertes
Infantiles
1
Matrimonios
65
Bajo peso
16
Defunciones
Divorcios
80
42
Madres
Adolescentes
26
Población
CV
4
Alzheimer
3
3,894,855
Muertes
fetales
1.5
Otras
38
Madres
solteras
77
Nacimientos
140
Condición
Causas de Muerte en PR
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.
Most Common Diagnoses, 2004
Rank
1
2
3
4
5
6
7
8
9
10
Most Common
Principal Diagnosis
Percent
Distribution
Essential Hypertension
Routine infant or child health check
Malignant Neoplasms
4.2
3.4
3.0
Acute upper respiratory infections,
excluding pharyngitis
Diabetes mellitus
Arthropathies and related disorders
Spinal disorders
Normal pregnancy
Rheumatism, excluding back
Specific procedures and aftercare
3.0
3.0
2.7
2.6
2.5
2.0
1.7
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.
Most Common Diagnoses; 1990 vs. 2004
1990
Rank
2004
Essential hypertension
Normal pregnancy
1
2
Otitis media
General medical examination
3
4
Acute upper respiratory
infections
Health supervision of child
5
Diabetes mellitus
7
Arthropathies and related
disorders
Spinal disorders
Allergic rhinitis
Bronchitis
8
9
Normal pregnancy
Rheumatism, excluding back
6
Essential hypertension
Routine infant or child health
check
Malignant Neoplasms
Acute upper respiratory
infections, excluding pharyngitis
Diabetes mellitus
Most common drug mentions, 2004
Rank
Therapeutic
Classification
Percent
Distribution
1
Antidepressants
5.1
2
3
4
5
6
7
8
9
NSAIDs
Antiasthmatics or bronchodilators
Antihypertensive agents
Hyperlipidemia
Antihistamines
Acid or peptic disorders
Antiarthritics
Blood glucose regulators
4.7
4.4
4.4
4.1
3.7
3.6
3.5
3.4
10
Non-narcotic analgesics
3.3
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
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
6
Other cardiovascular stress test
Microscopic exam of specimen
7
Biopsy
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
excision of tissue of skin…
excision of tissue of skin…
of skin and subcut. tissue
Summary
1.
2.
3.
4.
The Medicare PPS stimulated rapid growth of
ambulatory care programs.
Indian Health Services as the model for pharmacist
as a primary care provider
Pharmacist-managed clinics
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