Armin will be dead if politicians don't react now

With the end of the maximum legally possible term of eight years, the ARMIN model project, the Saxony-Thuringia pharmaceutical initiative, was ended on June 30, 2022. This means that a promising and now even positively evaluated care approach, which promotes and interlinks interprofessional collaboration between doctors and pharmacists for the benefit of the patient population being cared for together, is on the brink of extinction. It is no wonder that the actors used the opportunity when the evaluation data was presented to put forward political demands in order to maintain the positive effects of ARMIN beyond the end of the project and possibly even further develop them, although in the opinion of the ARMIN- Project partners must first create the necessary legal basis.

>> ARMIN was a project that created something very special in the federal states involved: a new reality of professionalism based on clear rules and coordinated processes.
Comprehensive healthcare for multimorbid patients who permanently take five or more active ingredients. Rainer Striebel, the chairman of the board of AOK PLUS, summed it up at the press conference to present the current evaluation data: “There is currently no legal framework in standard care that supports interprofessional collaboration between doctors on the one hand and pharmacists on the other hand, promotes and interlinks.” But according to Striebel, the possibility of continuing this care approach through selective contracts is also no longer possible. When asked by “Monitor Healthcare Research”, the AOK-Plus boss stated that the complexity of the project was so great that he had to comply with Section 140.
Selective contracts are not seen as a “relevant basis” that would not only enable enrollment hurdles to be as low as possible, but also the participation of other health insurance funds. Therefore, Striebel continues, his fund, which has high market shares in Saxony and Thuringia, is increasingly moving away from selective contractual regulations, since “what works well should be made available to everyone in the regions”.
By “works well”, the cashier definitely means ARMIN, which has managed to become a standard supply in Saxony and Thuringia over the course of the eight-year model. The results of the evaluation of Module 3, interprofessional medication management, were particularly good. Here Prof. Dr. sc. hum. Hanna Seidling from the Department of Clinical Pharmacology and Pharmacoepidemiology at Heidelberg University Hospital, who was engaged for the evaluation together with the aqua-Institut in 2019. This late point in time is a problem in itself: although the evaluation could take place while the model project was running, it started significantly later, at a point in time when it had actually already been implemented in routine care. The second problem arises from the study design chosen - because of the time lag - using a retrospective assignment of a control group using propensity score matching. According to Seidling, this means that possible selection effects cannot be completely ruled out, which could also distort the overall effect. Likewise, due to the study design, no causal or mechanistic conclusions could be drawn that could show what individual effects actually triggered.
Nevertheless, when comparing the patients from the intervention and the control group,
important results are shown in the troll group until the end of the individual follow-up period. The main endpoints, for example, are the risk of death and the risk of being hospitalized within the next two years. During the follow-up period, 9.3% of patients in the ARMIN group died, whereas 12.9% died in the control group. According to Professor Seidling, in the adjusted analysis (here the supposedly older age in the control group was taken out) the risk of dying in the ARMIN group was 0.84 times greater and therefore significantly smaller than in the comparison group. Seidling: “This corresponds to a covariate-adjusted absolute risk reduction of 1.52%, which in turn can be translated into a number needed to treat of 66.”
The number 0.84 is particularly important politically. This means nothing other than that the patients who took part in ARMIN medication management had a 16 percent reduced relative risk of dying compared to the retrospectively matched control group! With regard to hospitalizations, no difference could be found between ARMIN and the control group - the proportions of patients hospitalized within two years were the same in both groups. According to Seidling, it should also be noted that hospitalized ARMIN patients were hospitalized earlier and more frequently than those patients who were hospitalized in the control group.
The reasons for this could not be analyzed due to the study design, but Seidling ventured the interpretation that previous hospitalizations were a sign that the intervention group was being monitored more closely, which might have made it possible to recognize and react to certain situations more quickly. Seidling: “However, this is purely hypothetical and would only be one possible interpretation of the data.” It should also be noted that the hard endpoint of mortality has so far been examined relatively rarely in the analysis of medication management programs and even more rarely with positive results. The healthcare researcher sees a reason here for the results to be further examined and discussed. Likewise, from a scientific perspective, the data should be used to plan further and then prospective studies. With such study designs, it would then be possible to examine in much more detail where the triggers of such effects can be located, which intervention components are particularly successful and informative and, above all, which patient groups could particularly benefit from structured medication management.
Three demands of the ABDA
Gabriele Regina Overwiening, President of the Federal Association of German Pharmacists Associations, or ABDA for short, could only agree with this statement. According to the ABDA president, one of the biggest problems in the long-term treatment of diseases is that it is limited
Adherence or adherence to intake or therapy. “Medicines, the patients don’t
take, cannot work,” said Overwiening. But every patient would have the right to freely decide about his or her treatment. But, says the ABDA boss: “This decision doesn’t just affect your own health. If medicines are left in patients' cupboards, this causes enormous additional costs for the healthcare system.” Therefore, an important result of the ARMIN model project is that adherence to medication among participating patients has been demonstrably improved. In her opinion, an important building block for this was certainly the structured and repeated discussions with the patients. However, such detailed consultations went beyond the consultation in standard care in terms of time and content. In addition, many ARMIN patients would have found it positive that their medication plan was medically and pharmaceutically checked and updated, but also that they would have had a better overview of their current, complete and correct medication plan. Overwiening: “ARMIN has clearly shown that joint care by doctors and pharmacists brings many advantages to patients. We have to bring this into standard care.”
For this reason, the ABDA boss put three demands on record:
• Firstly, everyone should be included in standard care
Patients with polymedication have a
receive an annual review of their entire drug therapy. This review of drug therapy should be carried out by doctors and pharmacists.
the counters perform together – according to class
ren rules and in coordinated processes. The rewarded medication analysis by pharmacists was introduced with the pharmaceutical services in June 2022, but that does not go far enough. “In ARMIN we learned that doctors and pharmacists can and should work more closely together. Now, when reviewing the overall medication, the responsibilities of the doctors and also their fees must be determined,” demanded the ABDA President, who was clearly on the side of the medical profession.
• Secondly, if the annual joint medication analysis is not sufficient at the discretion of the doctor or pharmacist, patients in regular care should be entitled to continuous care jointly by the doctor and pharmacist. According to Overwiening, this would be in line with ARMIN medication management, which has shown such great benefit. The ABDA
Boss: “We learned from ARMIN, and this is also confirmed by other studies, that simply printing out a medication plan is not enough to generate patient benefit.”
• Therefore, the third requirement was: If one of the focal points of the measure is to be adherence to medication, the medication plan must be explained orally to the patients in accordance with their individual knowledge.
For all of these requirements, all patients who use multiple medications need individually tailored care options. Overwiening: “The benefit is greatest where doctors and pharmacists work hand in hand for the benefit of their patients.” ARMIN has proven that this can be implemented in everyday care.
KV: per standard supply
“That wasn’t a study, it was standard care.” With these words, Dr. med. Annette Rommel, the first chairwoman of the board of KV Thuringia, who from the beginning viewed the model project “a bit as my little son”, which grew very slowly, is what ARMIN is all about: the patient benefits that have now become clearly visible . According to the Thuringian KV boss, ARMIN was not attended by a selection of people who were particularly interested in their health, but by the clientele who were cared for in the family doctor's practice
– a large number of chronically ill patients who would have to take five or more medications at the same time. Therefore, the issue of compliance, but also the issue of interaction and avoidance of undesirable side effects, is extremely important. As a specialist in general medicine and, above all, as a rural doctor, she knows this from her own experience because she has a lot to do with patients who find themselves in exactly such situations. Rommel: “That's why it was very important to all of us to enter into cooperation with the pharmacists in Thuringia and Saxony.” Cross-sector care, Rommel continues, is often a nice slogan, but here you can clearly see that the regulated and targeted cooperation between experts to improve patient care
could enable tensile supply.
Rommel also spoke of problems and stumbling blocks. The industry producing practice management systems would not have worked the way “we wanted” and implemented “our modules 100 percent”. Some colleagues who wanted to take part in the ARMIN model were disappointed because the practice software providers withdrew from this topic. Rommel: “This is a huge issue in Germany. Our digitalization in the healthcare system is also suffering from this.”
Despite everything, the KV boss clearly advocates for the project approach to be continued, provided that the appropriate legal framework for standard care has been created by the federal legislature. Then ARMIN can also be used across the board in the Federal Republic. However, she rejected Overwiening's request for an annual review of the entire drug therapy. She doesn't believe that a patient's right to an annual medication check actually needs to be regulated. This depends too much on the individual patient. However, it is clear that there must be clearly defined tasks for pharmacists and doctors regarding medication management, medication catalog and active ingredient prescription. Rommel: “We also need a digital solution for the medication plan.” And an obligation for the software industry to introduce the necessary modules accordingly. Last but not least, there also needs to be appropriate remuneration for the additional services provided by doctors and pharmacists. <<
by: MVF editor-in-chief Peter Stegmaier