Yesterday I was lucky enough to get some time to visit a polyclinic with an am care pharmacist who happens to have graduated from UCSF in 2006. A polyclinic here is owned by the government and provides heavily subsidized care to the local communities, much like the Healthy SF clinics in San Francisco or Vista Community Health Center in Santa Rosa. The specific clinic I visited today was a diabetes, hypertension, hyperlipidemia clinic which was a great experience for me since I was able to compare with my internship in the same setting back in the US.
Much like in the hospital, am care here is evidence based with guidelines, probably because the pharmacist who runs the clinic was trained in the US. She has a total of 6 clinics scattered across the country and after establishing them about 4 years ago, she's now in charge of training new pharmacy grads to work in am care. At the community level, like in the US, physician pay is less than private practice so a majority of the physicians only do the work here because they really like working with the local, disadvantaged population. The problem is many of them are part time so they rotate through clinics frequently and patients often see a different physician at each visit. They get tired of telling the same story of their medical history to each new physician so at some point they just stop being as responsive. The great thing about the pharmacy clinics here is that the pharmacist becomes a familiar and steady face to the patient because they don't rotate like the physicians. Many times, as in the states, the patient becomes more comfortable discussing issues with the pharmacist rather than the doctor because of the rapport that has been built up so it is very good to see that pharmacy here also takes a major role in patient care on the teams.
We still follow ADA, JNC7, CHEST, etc here to make clinical decisions but there are some nuances that make things a little more difficult. Because of the way the health care system is set up here, each visit incurs a copay with the pharmacist. It's usually very cheap, about $5, so it doesn't deter the patient and it pads pharmacy's budget a little. The issue is when the patient is prescribed a medication, the cost of the drug is fully the patient's responsibility and it is calculated per tablet. If the patient needs say 30 mg of atorvastatin, it would save them money if you prescribe 40 mg of atorvastatin instead so that you wouldn't need 2 separate prescriptions of 20 mg and 10 mg which doubles the cost for the patient. It's actually a pretty good way to make sure that patients don't abuse the system to get extra medications, but it would be impossible to implement in the US.
I think the biggest challenge I saw here was that patients do not perform SMBG for their diabetes. Like in the states, the device is usually cheap to free but the test strips cost a small fortune. Because there is no insurance for these low income patients (the government does not pay for the medications unless you fulfill certain very strict requirements), the full cost of the strips falls on the patient. As a result, patients will usually only SMBG maybe 2-3 times a week if at all and most only get fasting BG readings when they come to the clinic visit.
Since the patients don't SMBG, the pharmacists here rely much more heavily on the A1c to determine control. The fasting BG on the day of the clinic just gives a snapshot that may or may not be helpful. If the A1c is >8.3, the pharmacists know they can be more aggressive in titrating insulin (faster than the normal 2 units we were taught in school). I've found that patients here really aren't that resistant to starting insulin, unlike in the US. Part of the reason might be because everything is in an insulin pen. Lantus solostar actually costs less than the Lantus vial so it saves the patient money and helps improve adherence by making it easier for the patient to use the insulin. The diabetes cases here are more deceptive for the fact that many of the patients who have DM appear rather thin. I also see a lot more Januvia here for some reason but I'm not sure why. Overall, a worthwhile visit to the primary care clinic here to see am care practice in another country and note the subtle differences.
No comments:
Post a Comment