ONE of the challenges faced by health professionals of all disciplines is to work together to improve quality of care while reducing its cost to society. With this in mind, in 1997 the Medical and Pharmacist’s Association in Fribourg, Switzerland, launched a pilot project called ‘Physicians and Pharmacists Quality Circles for Drug Prescription’. Two years later, the Project’s founders presented their first assessment1, showing encouraging results in human, professional and economic terms - and showing why others have much to learn from the Swiss experience.
Ambitious objectives, modest means
When the Quality Circles team launched its Project, with the backing of four health insurance funds, its objectives were clear. It wanted to: improve the quality of care; improve the relationship between local physicians and pharmacists; evaluate a method of interdisciplinary, locally run continuing education; and make the savings expected by political authorities and health insurance funds without sacrificing quality of care.
The Project’s initiators organized themselves into a Professional Interest Group, which coordinated the Circles’ work. They then negotiated with the Swiss Pharmaceutical Society’s Quality and Development Department to provide the Project’s documentation service. The Department does research and selection of current evaluated and comparative clinical and therapeutic data, economic data and international recommendations.
The Group also entered into a collaborative agreement with the Swiss Insurance Companies and Sickness Funds Billing Office, to obtain the statistics needed for drawing up a prescriber profile of each participating physician. This means the Group can monitor the Circles’ work and evaluate their impact. The Office sells the data if confidentiality is guaranteed. All participating prescribers have to inform the Billing Office that they agree to their prescribing information being given to the Professional Interest Group. An ad hoc management committee of physicians, pharmacists and insurers was set up to liaise with insurance companies and sickness funds.
Each of the six Quality Circles generally included five physicians and a pharmacist, all unpaid volunteers. The Circles decided that within the first two years they would study 12 therapeutic classes and debate a number of ‘medical attitudes’ (see box). The therapeutic classes covered by the programme accounted for two-thirds of the Canton (county) of Fribourg’s drugs bill: antibiotics, antidepressants, antihypertensives, non steroidal anti-inflammatory drugs, beta-blockers, diuretics, cholesterol-lowering drugs, calcium blockers, antipsychotic drugs, hypnotic drugs, tranquillisers and vasodilators.
The Project studied medical attitudes to:
• Prescribing antibiotics for common infections in out-patient treatment;
• Hypertension, heart failure, angina pectoris and post-infarction;
• Rheumatism, muscle pain and prevention of the undesirable effects of non steroidal anti-inflammatory drugs;
• Blood lipid disorders and prevention of cardiovascular disease;
• Depressive and/or anxious patients;
• Sleep disorders;
• Generic substitution;
• Therapeutic innovations;
• Drug interactions.
While the Professional Interest Group ensured coordination of the Circles’ work, the pharmacists were responsible for the links between the Group and the Circle to which they belonged. The pharmacists held monthly meetings with the Swiss Pharmaceutical Society’s Quality and Development Department, to obtain current scientific and economic data on the topics the Circles studied. This gave them the opportunity to update and expand their own knowledge before passing the information on to the doctors.
Physicians-Pharmacists Quality Circles Generic substitution between 1997-1999
Source: O. Bugnon and coll., Swiss Association of Pharmacists, 2000-2001
In their enthusiasm for the initiative, physicians and pharmacists met regularly. At exhaustive 2-3 hour sessions, they compared the risk/benefit of drugs in one or several classes and discussed drug prescribing patterns. Participants tried to agree a set of treatment options based on fixed objectives: first of all improving care quality, and secondly finding the most economical solutions. Once back in their surgeries, prescribers tried to put into practice the strategies that had been chosen collectively - the fruit of their hard work.
The Circles’ first two years reflect these health professionals’ commitment to working together, achieving the initial objective of improving relations between physicians and pharmacists. The Swiss General Practitioners’ Association now recommends that doctors take part in Quality Circles, counting this work as part of in-service training.
The Circles’ economic impact has been analysed by the Swiss Pharmaceutical Society. The Society used data from the Swiss Insurance Companies and Sickness Funds Billing Office to calculate the cost of drug prescriptions (corresponding to the topics addressed in the Circles) for the first seven months of 1997, and for the same period in 1998. These costs were compared to those of reference groups, drawn randomly from a list of doctors with practices comparable to those of physicians in the Circles.
Findings included that the overall cost of antibiotic and hypertensive drug prescriptions was higher in 1998 than in 1997, but less so in Circle prescribers than reference groups. The overall cost of painkillers, anti-inflammatory drugs and drugs to treat rheumatism fell by almost 4% between 1997 and 1998 in the Circles, while increasing in the reference groups. And there was a significantly higher increase in generic prescribing among the Circles than the other groups. For example, in 1998, the change in the proportion of generic drugs to treat hypertension was + 11.7% among the Circles compared with +1.8% among the reference groups.
A thought-provoking example
The Swiss Physician-Pharmacist Quality Circles in Fribourg have demonstrated that health professionals are capable of launching a movement to reorganize health care at local level, without waiting for solutions “from above”. Circle members believe that the initiative could be extended to other parts of Switzerland or beyond, provided that all the partners involved in organizing care, and particularly insurers, participate.*
* A recent update showed that by 2001 three other Swiss Cantons had launched Quality Circles, adding to those established in Fribourg.
Even if there is no guarantee that the community’s overall health costs will be lower, there is every reason to believe that health professionals are collectively capable of offering means of improving patients’ care. The Swiss experience is a source of fresh inspiration for health professionals in other countries.
For further information contact: O. Bugnon, Swiss Association of Pharmacists, Station-strasse 12, CH-3097, Bern-Liebefeld, Switzerland. Fax: +41 31 978 58 59.
1. Bugnon O. et al. Développement continu de la qualité de la chaîne des soins: cercles de qualité médecins - pharmaciens pour la prescription des médicaments (Ongoing development of the quality of the care chain: physicians and pharmacists quality circles for drug prescription) 1999. Unpublished document.
Source: la revue Prescrire, February 2000.