Study on the Management of Chronic Diseases in American and British Community Pharmacy

Chen Qianqian,Tian Lijuan

(School of Business Administration,Shenyang Pharmaceutical University,Shenyang 110016,China)

Abstract Objective To provide a reference for promoting the construction of chronic disease management in community pharmacies in China.Methods Literature research and comparative research methods were used to analyze the management of chronic disease carried out by community pharmacies in the United States and the United Kingdom.Results and Conclusion The management of chronic diseases in American and British community pharmacies has formed retail health clinic and online chronic disease mode.It is recommended that Chinese government should issue measures and supporting guidelines for the management of chronic diseases in community pharmacies as soon as possible.Community pharmacies should be encouraged to carry out chronic disease management with the concept of prudent inclusion and gradual progression.Meanwhile,the concentration of drug retail industry should be improved to carry out the systematic construction of chronic disease management and build a standardized chronic disease service process.Besides,community pharmacies should make full use of new technologies such as the Internet,cloud computing and big data,smart wearable devices,and chronic disease management Apps to explore and carry out online professional chronic disease management mode.

Keywords: the United States;the United Kingdom;community pharmacy;chronic disease management

1 Introduction

Chronic diseases are short for chronic noncommunicable diseases,mainly referring to one or more diseases such as cardiovascular and cerebrovascular diseases (hypertension,dyslipidemia,coronary heart disease,and stroke,etc.),endocrine disorders (diabetes,hypothyroidism,and hyperthyroidism,etc.),malignant tumors,respiratory diseases (asthma,chronic obstructive pulmonary disease,chronic tracheitis,and emphysema,etc.),mental and neurological diseases,which have a long course,complicated causes,health damage and serious social harm[1].According to the “Progress in Disease Prevention and Control in China” issued by the former National Health and Family Planning Commission in 2015,the deaths caused by chronic diseases had accounted for 85% of the total deaths in China,and the disease burden had accounted for 70% of the total disease burden,which became an important cause of poverty for the public.If not timely and effectively controlled,it would bring serious social and economic problems.

Community pharmacies are the main places for patients with chronic diseases to purchase drugs,whose essence is a service site to solve health problems.It is also one of the important modes for chronic disease management[2].Chronic disease management refers to a scientific management mode in which professional physicians,pharmacists,nurses and dietitians of chronic diseases are organized as a medical team to provide disease consultation,regular detection,risk assessment,comprehensive intervention and services for patients with chronic diseases.Therefore,it can promote health,delay the disease process,reduce complications and the disability rate,prolong life span,improve the quality of life and reduce medical costs[3].As a mode of chronic disease management,community pharmacies have the following advantages.Firstly,pharmacies can fill the gap in chronic disease services for disease tracking and follow-up of patients after discharge.Secondly,pharmacies are the preferred place for patients with chronic diseases to purchase drugs regularly.Compared with hospitals,they are widely distributed,large in quantity,close to patients,and they are frequently visited by patients.Thirdly,pharmacists in community pharmacies give patients more timely medication guidance and supervision services,reducing the incidence of irrational drug use and improving medication compliance.

2 Mode for chronic disease management of community pharmacy in the United States and the United Kingdom

2.1 Mode for chronic disease management of community pharmacy in the United States

2.1.1 Retail health clinic mode

The retail health clinic mode for chronic disease management takes retail pharmacies as the main body and cooperates with multi-parties.Retail health clinics are usually equipped with professionals such as nurses,physician assistants,and pharmacists,who can provide many services such as chronic disease diagnosis,prescription issuance,medication guidance,health tracking,and patient referral.Partners in retail health clinics include manufacturers,insurance companies,and health care organizations.

Walgreens opened more than 300 retail health clinics in 19 States in 2013,which became the first retail pharmacy to carry out chronic disease management,covering a variety of chronic diseases such as asthma,diabetes,cardiovascular disease,chronic obstructive pulmonary disease,depression,and high cholesterol[4].In 2018,CVS Health acquired Target’s pharmacies and clinic businesses,and opened more than 1 100 retail health clinics in 33 States in a shop-in-shop mode.Currently,CVS Health and Walgreens account for three-quarters of the market share of retail health clinics in the United States,followed by Kroger,Walmart and Rite Aid[5].

The retail health clinic mode builds a differentiated competitive advantage by establishing partnerships with different partners of the health system.For example,CVS collaborated with Alere eScreen,an instant diagnostic test manufacturer,to improve the convenience of chronic disease detection by using Alere eScreen services for chronic disease health screening (biometric screening,physical examination,drug testing,etc.).In addition,CVS integrated with Aetna,a health care insurance company,to provide more affordable services to patients with chronic diseases at a lower price.Walgreens and nonprofit Providence Health &Services collaborated and built its own clinics in stores,forming a differentiated competitive advantage in coordinating care for chronic diseases and providing mental health services[6].Besides,Walgreens joined Accountable Care Organizations (ACO),actively participating in the “Medicare Shared Savings Program (MSSP)”[7].ACO is a voluntary group composed of doctors,hospitals and other health care providers.Through cooperation with ACO,Walgreens hopes to provide coordinated and high-quality care for patients with chronic diseases while attracting more patients flow.Walgreens integrated the resources to avoid repeated medical treatment and reduce medical costs,which promoted its integration into the basic medical chain in the United States.

Retail health clinics have the following advantages: (1) For retailers,it can benefit from the increased number of pharmacies and patients fiow to help establish patient loyalty;(2) For patients with chronic diseases,it not only reduces cost expenditure for health care,but also obtains meticulous professional chronic disease management[8].

2.1.2 Online chronic disease management mode

Online chronic disease management is a new mode to provide services outside the traditional physical environment.Through telemedicine technology,the development of APP,digital health products,electronic equipment and other tools,online chronic disease consultation,diagnosis and treatment,monitoring,intervention and other chronic disease services can be provided to patients with chronic diseases.Therefore,they do not need to go to the hospital for treatment,which will improve the efficiency of chronic disease management.

Walgreens is taken as an example to introduce the process of providing online chronic disease management.

(1) Walgreens and MD Live collaborated to release a new telemedicine service APP,which provides a precise and intelligent health service platform.Patients with chronic diseases can consult practitioners at any time through mobile terminals to meet their online treatment needs[9].

(2) Walgreens collaborated with New York-Presbyterian to carry out the “NYP On Demand Project”.They set up emergency health kiosks in some offline stores of Walgreens,where patients with chronic diseases can undergo real-time physician consultation and basic health examination by means of high-definition video calls[10].

(3) Using wearable devices,patients can achieve online home chronic disease monitoring.Wearable devices can measure whether the activity is up to standard by counting the steps,and also provide services such as symptom monitoring and sleep tracking,which helps to track the trend of patients’activity and health balance.Therefore,it promotes patients to understand the chronic disease management plan clearly,thus achieving the purpose of improving prognosis and cost control.

(4) Walgreens collaborated with WebMD to develop a digital health platform “my WalgreensTM”,which helps patients who want to improve their health status by changing their lifestyle to establish personalized goals and intervene in their medication and lifestyle in a timely manner[11].Relying on this platform,Walgreens launched the “Balance®Rewards for Health Choices” program,in which patients with chronic diseases can obtain reward scores for health behaviors by participating in the program to complete the corresponding health goal activities.In addition,the scores can be used to purchase drugs in the Walgreens online store of the WebMD application,thereby improving medication compliance and increasing patient loyalty.

2.1.3 Comprehensive management of health alliance Mode

As one of the American chain pharmacies,Rite Aid constructed the comprehensive management mode called Health Alliance in 2014,which consists of Rite Aid and its chronic disease management and data analysis subsidiary Health Dialog.It can provide whole-process chronic disease management services for patients.

In this mode,pharmacists of Ride Aid cooperated with the full-time health coaches of Health Dialog,continuously to provide some services such as drug prescription review,nutrition and weight management,disease education,exercise guidance,and smoking cessation support to patients,which can improve the overall health level and self-management ability of patients with chronic diseases.Pharmacists can give full play to their professional advantage in reviewing physician prescriptions,giving patients medication guidance and improving medication compliance.In addition,these pharmacists can urge patients to continue their medications in a timely manner and perform the necessary examination before their medication.Full-time health coaches can provide personalized health guidance services for patients,design personalized diet,weight loss,and exercise programs based on physician’s diagnosis and patient prognosis,and ensure program implementation through courses,remote regular communication (such as mobile phones,telephone calls,etc.),and nurse return visits[12].

In a 19-month follow-up survey of a group of users by Health Dialog in 2015,the data showed that users who should lose weight lost 8 pounds on average.76% of users who should lower their blood pressure achieved the goal of lowering blood pressure.And 34% of users who should reduce their blood glucose achieved the goal of lowering blood glucose.

This mode greatly promotes collaboration among health care service providers to build a health alliance,which will provide comprehensive health management for patients with one or more chronic diseases,such as congestive heart failure,chronic obstructive pulmonary disease (COPD),high cholesterol,and diabetes[13].

2.2 Diversified service mode for chronic disease management of community pharmacy in the United Kingdom

The National Health Service (NHS) in the United Kingdom is divided into four major components:Administrative departments,service purchasing agencies,supervisory regulating agencies and data and evidence agencies,and health service providers[14].At the national level,service purchasing agencies are commissioned by the NHS to purchase most of the country’s health services and determine access to local Clinical Commissioning Groups (CCGs),which are responsible for purchasing local health care services.

In April 2005,the United Kingdom introduced community pharmacy contractual framework (CPCF),which completed the reform of community pharmacies and designed three different levels of service types,including basic services,advanced services,and value-added services,which incorporated chronic diseases into community pharmacy management with a diversified pharmaceutical care mode[15].Pharmacies should assess their capacity to provide services first,and then they can apply for categories of services accordingly to carry out the prescribed pharmaceutical care program after contracting with the NHS.

Basic services are compulsory services as prescribed by the government.The community pharmacy must provide 7 basic service items after signing the contract,including drugs and medical device dispensing,long prescription dispensing,recycling waste or spare drugs,providing advice on healthy lifestyle,providing referral guidance,self-care counseling,and clinical management.Patients with chronic diseases can obtain chronic disease services such as advice on a healthy diet,smoking cessation and moderate exercise,reviewing and dispensing long prescriptions,advice on providing referrals and supporting documents from pharmacists through pharmacies[16].

Advanced services belong to selective services of community pharmacies.NHS has established a dynamic update mechanism for service content.When the contracted pharmacy meets the requirements specified in the Secretary of State directions,it can provide any advanced services[17].By October 2021,NHS had required a nationwide contracted pharmacy should set up 10 kinds of advanced services,including new drug prescription,medical device management,stomatal device customization,community pharmacist consultation,hypertension case examination and epidemic drug delivery[18].Both contracted community pharmacies and pharmacists must be appropriately certified and assessed to implement advanced services.By carrying out new drug prescription services,pharmacists can help patients with chronic diseases such as COPD,diabetes,and hypertension fully understand the new prescription information (such as indications,medication time,medication dose,etc.) and improve their medication compliance.Hypertension screening service was initiated in October 2021,which is provided only by pharmacists in two phases: one is to identify people at risk of hypertension and provide them with blood pressure measurements;the other is to provide 24-hour ambulatory blood pressure monitoring.

Enhancement services belong to local services entrusted by CCGs to community pharmacies contracted with the NHS,which is responsible for managing and monitoring the implementation effects of the enhancement services[19].Provisions for enhanced services are specified in “Pharmaceutical Services (Advanced and Enhanced Services) in 2013”,including: anticoagulant monitoring,elderly care support,independent prescription,disease screening,smoking cessation,supplementary prescription,and drug management for specific diseases[20].

In the United Kingdom,through a top-level design,some chronic disease services of general practitioners are transferred to community pharmacies,and pharmacists in community pharmacies become important providers of health care for patients with chronic diseases.Specifically,general practitioners in clinics identify and diagnose patients,and after comprehensive judgment,patients with minor chronic diseases are referred to community pharmacies for subsequent comprehensive chronic disease management[21].

The diversified service mode of chronic disease management in British community pharmacies can not only make patients with chronic diseases obtain professional and comprehensive care quickly,but also reduce the workload of general practitioners,which further optimizes the tiered diagnosis and treatment system,helping general practitioners reasonably allocate time to diagnose and treat critically ill patients.Therefore,it integrates the medical resources of the United Kingdom to a large extent and saves medical expenses.

2.3 Comparison and experience of chronic disease management of community pharmacy in the United States and the United Kingdom

The chronic disease management of community pharmacies in the United States is mainly implemented by Walgreens,CVS and Ride Aid.In 2020,the number of stores in these three pharmacies exceeded 50% of the total number of retail pharmacies in the United States,with a market share of more than 80%.The highly concentrated drug retail industry is an important factor to promote pharmacies to explore and carry out the management of chronic diseases[22].The health service system supported by public funds has promoted the formation and development of chronic disease management modes in British community pharmacies.In addition,favorable policies,utilization of online resources,and active construction of partnerships are also factors of high maturity in chronic disease management in the United States and the United Kingdom.By integrating and using the resources of all parties,the United States and the United Kingdom have formed a mature diversified chronic disease management mode in community pharmacy,and the comparison of the management modes between the two countries is shown in Table 1.

Table 1 Comparison of the mode for chronic disease management of community pharmacy in the United States and the United Kingdom

At present,the management of chronic diseases in community pharmacies in China is still in the preliminary stage,and there is no appropriate chronic disease management mode.Besides,the national medical and health authorities have not included community pharmacies in the system of chronic disease prevention and control.The concentration of the drug retail industry is not high,and drug retail enterprises are large but not strong.In 2020,the top 10 drug retail enterprises account for 20.9% of market share[23].In large chain pharmacies such as Guoda Pharmacy and Neptune Star Pharmacy,the development of chronic disease management has emerged,but there are problems such as imperfect chronic disease management system,inappropriate mode,and unclear process.Therefore,based on the development level and macroscopic environment of community pharmacies in China,it is necessary to construct a reasonable mode of chronic disease management in community pharmacies by referring to the advanced experience of American and British community pharmacies.

3 Implications

Favorable policies should be formulated to encourage community pharmacies to carry out chronic disease management with the concept of prudent inclusion and gradual progress.The dispensing separation was realized in the United States in the 18th century,and pharmacists in community pharmacies have prescription rights[24].The United Kingdom government implements a reimbursement system of “pharmacy services,national payment”,which provides financial support for pharmacies to carry out chronic disease management.At the same time,pharmacies provide financial support by working with NHS contracts to carry out multi-level optional chronic disease services.At present,China promotes dispensing separation through reforms such as drug centralized procurement and long prescription pilot.However,its effect on promoting the development of chronic disease management is not clear.It is recommended that China should build a chronic disease prevention and control system with collaborative management of Centers for Disease Control and Prevention,hospitals,grassroots medical institutions,professional prevention and control institutions and community pharmacies to set up a chronic disease prevention and control network.Corresponding management measures and supporting guidelines should be issued for community pharmacies to carry out chronic disease management,such as clarifying the qualification and start-up conditions,standardizing the management of diseases and basic service processes to encourage pharmacies to independently innovate service methods.Besides,the government should provide certain financial support for community pharmacies to carry out chronic disease management,continuously reform the medical insurance payment,explore the possibility of medical insurance to purchase chronic disease management services,and improve the enthusiasm of pharmacies and patients to participate in the management.

The concentration of retail industry should be improved and a standardized service process must be established for chronic disease management.The construction of chronic disease management mode in community pharmacies requires a lot of funds,professional personnel,and improvement of conditions,which may not obtain significant benefits in the short term.Leading enterprises of chain pharmacies in the United States built a mature chronic disease management mode relying on their stores all over the country with strong financial support and complete supply chain[25].The improvement of concentration is also the premise of good development of chronic disease management in the drug retail industry.Only large-scale chain pharmacies can ensure sufficient capital investment.Using their industry influence and appeal,they can explore and practice effective chronic disease management modes,which further strengthens enterprises.The pharmaceutical retail industry should strengthen differentiated competition and innovate business modes.They can use policy dividends to actively lay out the prescription outflow and long prescription market,taking the lead in the change,and promoting the systematic construction of chronic disease management in community pharmacies with a standardized service process while improving the concentration of the industry.The specific steps are as follows: (1) Take the detection of basic physical health indicators as the entrance to screen out the potential health risk factors of patients;(2) Establish the electronic health records of patients,including but not limited to recording the patient’s previous health diagnosis and treatment information,medication regimen,and disease progression;(3) Chronic disease professionals and patients jointly develop a longterm monitoring plan for medication and personalized management;(4) Chronic disease professionals actively carry out follow-up and tracking for patients,and timely give guidance on diet,exercise,behavior and other life aspects;(5) Pharmacies provide patients with a mobile health counseling platform,such as APP.Meanwhile,chronic disease professionals can provide patients with medication guidance and mental health counseling,which is beneficial to their physical and mental health.

Internet technology should be made full use to strengthen cooperation in the industry.With the continuous development of internet,cloud computing,big data and other technologies,new tools such as smart wearable devices,chronic disease management APPs and WeChat,community pharmacies should carry out online professional and convenient chronic disease management modes[26].The cooperation among grassroots medical institutions,commercial insurance companies and industry associations should be enhanced to give full play to their advantages[27].For example,doctors in primary medical institutions can diagnose and treat patients,create patient health information files,and issue electronic prescriptions.An electronic prescription circulation of patient health record platform should be stablished through national overall planning.Then,grassroots medical institutions can share prescription information with community pharmacies,and provide pharmaceutical services such as prescription review,drug dispensing and recording of patients’ full-course medication.In addition,community pharmacies should actively develop intelligent and information-based chronic disease management tools and continuously and innovate chronic disease management systems.