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Denmark has a social welfare system
in which all citizens receive health
care, social services, and pensions. Med-
ical care and surgery are free. Denmark
has a population of 5.4 million. Its resi-
dents are served by 322 pharmacies, cor-
responding to 16 700 inhabitants per
pharmacy.1Pharmacy is a profession
subject to comprehensive state regula-
tion by the Danish Medicines Agency
regarding price, location, and number of
pharmacies.2Torun a pharmacy, a per-
son must hold an MSc degree in phar-
macy.Regulating location aims to ensure
that everyone has reasonable access to a
pharmacy, even in rural areas where
pharmacies may not be profitable.
The Ministry of Interior and Health
and the Danish Pharmaceutical Associa-
tion (the association of pharmacy own-
ers) fix the total gross margin of the
pharmacies every 3 years on the basis of
current figures and forecasts.
Pharmacy Education
Denmark has only one institution, the
Danish University of Pharmaceutical
Sciences (DFU), that confers an MSc de-
gree in pharmacy. In 2005, the DFU had approximately
1200 bachelor’s and master’s students, 110 PhD students,
and 70 students attending the continuing education mas-
ter’sprograms.3The DFU also offers a one year degree
program for pharmacists, Master of Drug Management.4
Sixty percent of graduates go to work in industry,while
20% take a position in a community pharmacy and 20% in
the public sector.
Pharmakon (Danish College of Pharmacy Practice) is
an educational center owned by the Danish Pharmaceutical
Association. Pharmakon educates all Danish pharma-
conomists (pharmacy assistants) in a 3 year program, and
there are currently about 470 students.5,6 The Ministry of
Education regulates the program.
Pharmaceutical Care in Community Pharmacies:
Practice and Research in Denmark
Hanne Herborg, Ellen Westh Sørensen, and Bente Frøkjær
Author information provided at the end of the text.
The Annals of Pharmacotherapy n2007 April, Volume 41 n681
www.theannals.com
OBJECTIVE:T
oreview the current status of Danish community pharmacy in both
practice and research and discuss future trends.
FINDINGS:Denmark has a social welfare system that provides health care, social
services, and pensions to its population. Medical care and surgery are free.
Prescription medicines are reimbursed by an average of 56%. Community
pharmacies are privately owned, but the health authorities regulate drug prices
and the number of pharmacies. At present, Denmark has 322 pharmacies,
corresponding to 1 pharmacy per 16 700 inhabitants. All pharmacies provide
prescription and over-the-counter products, advice about medicine use, dose
dispensing, generic substitutions, and administration of individual reimbursement
registers. Except for very simple processes, compounding is centralized at 3
pharmacies. Many pharmacies offer measurement of blood glucose, blood
pressure, and cholesterol, and 60% offer inhalation counseling, a reimbursed
service. Research in pharmacy practice is well established and conducted
primarily at universities and at Pharmakon A/S, which is owned by the Danish
Pharmaceutical Association.
DISCUSSION:Extended services in clinical pharmacy are priorities for all Danish
pharmacy organizations. Reimbursement is sought at the national level, as well
as from payers in the new local authority structures in Denmark. The trend in
research focuses on collaborative health care, on developing and documenting
the value of community pharmacy services, and on optimizing services and
strengthening implementation.
CONCLUSIONS:Denmark has few,but large, community pharmacies and a long
tradition of research and development resulting in several well-documented
cognitive and clinical services. However, few services are reimbursed and
implementation is still a challenge.
KEY WORDS:community pharmacy services, Denmark.
Ann Pharmacother
2007;41:681-9.
Published Online, 27 Mar 2007,
www.theannals.com
,DOI 10.1345/aph.1H645
PHARMACEUTICAL CARE WORLDWIDE
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The pharmacy owner is responsible for ensuring contin-
uing competence development. In addition, the agreements
between the trade unions and the Pharmaceutical Associa-
tion give employed pharmacists and pharmaconomists the
right and obligation to attend one course annually at the
expense of the pharmacy owner.
Pharmaceutical Market
Denmark’s per capita consumption of pharmaceuticals
is $239 (USD; the exchange rate USD/DKK as of 7
November 2006 was 587), well below that of other West-
ern European countries (measured as sales in ex-factory
prices in the primary and hospital sectors and including
both prescription and nonprescription drugs). The public
medicines expenditure’s share of gross national product
(GNP) is 0.4% for Denmark, lower than in any other West-
ern European country.7
In 2005, the sales of medicinal products in the primary
healthcare sector were $2035 million (calculated in terms
of retail pharmacy price, including prescription charge and
value-added tax; in Denmark, 25% on all goods). In the
hospital sector,the amount was $750 million. Trade in
over-the-counter (OTC) products amounted to $320 million,
apart of which was sold through authorized retail outlets
($35 million). In 2005, the consumption of medicines was
1262 defined daily dosages (DDD) per 1000 inhabitants per
day.8The DDD, as defined by the World Health Organiza-
tion (WHO), is the assumed average maintenance dose per
day for a drug used for its main indication in adults.9
The National Health Security System reimburses
medicine expenses to the public.10 In the primary care sec-
tor,pharmaceutical expenditure is financed by the National
Health Security System (56%), patient copayments (39%),
and local authorities (4%). The cost of public reimburse-
ment for drugs in the primary health sector increases
steadily.Reimbursement is related to the patient’sannual
expenses for medicines. As of 2006, percentages were 0%,
50%, 75%, and 85%. Annual expenses below $82 are not
reimbursed. The reimbursement status for an individual
drug is based on its main indication, but other indications
also trigger reimbursement. Ordinarily, only drugs subject
to prescription are eligible for reimbursement. Approxi-
mately half of all pharmaceutical products on prescription
are reimbursed.
Private sickness insurance is quite common in Den-
mark; about 1.9 million (29%) people receive reimburse-
ment from private insurance.11
Organization and Delivery of Pharmacy Services
Pharmacy services are provided by the staffand the
pharmacy owner. The staff is composed of pharmacists,
pharmaconomists, and students (after completing an ap-
prenticeship at a pharmacy). These people have the com-
petence to handle and check prescriptions, dispense drugs,
and provide information.12 Pharmacy owners must ensure
that their staff members have the basic education and con-
tinuing training to enable them to perform their tasks prop-
erly. In 2005, the number of full-time employees (includ-
ing the owner) was 14.2 per pharmacy: 578 pharmacists,
2597 pharmaconomists, 456 trainees, and 667 others.1The
number of prescriptions handled per pharmacy (or branch
pharmacy) was 167 000 in 2005, corresponding to the han-
dling of 630 prescriptions per pharmacy per day. The num-
ber of pharmacies and employed pharmacists is decreas-
ing, while the number of pharmaconomists is increasing.
The number of pharmacies in Denmark has decreased over
the past 30 years.
Danish pharmacies are comparatively large. In 2006,
there were 322 pharmacies, of which 54 were branch phar-
macies.1Branch pharmacies offer the same services as
pharmacies. Medicine may also be sold in other types of
pharmacy-operated outlets without pharmacists. Pharmacy
outlets (138) are served only by pharmaconomists. In rural
or scarcely populated areas, shops under the supervision of
apharmacy are allowed to act as OTC outlets or delivery
facilities (691 and 251, respectively).
Starting in October 2001, other outlets (eg, supermar-
kets and kiosks) have been permitted to sell a selection of
OTC products. However, the total consumption of OTC
medicine did not change despite the increased number of
outlets. The pharmacies’ share (in DDD) of the OTC
medicine was 90% in 2005.1
Health Service Policy in Denmark
The purpose of the National Health Service is to pro-
mote public health and to prevent and treat disease, suffer-
ing, and functional limitations in individuals. The tasks of
the health service are laid down in the legislation.13 The
Act sets out health service requirements with regard to en-
suring respect for the individual, individual integrity, and
self-determination, and to meet the need for:
1. easy and equal access to the health service,
2. quality treatment,
3. cohesion between services (seamless care),
4. freedom of choice,
5. easy access to information,
6. transparency in the health service, and
7. short waiting time for treatment.
In 2004, the public share of expenses for health care was
79%, and the share of GNP allocated to health care ex-
penses was 5.8%. The cost of health care per inhabitant in
Denmark is about $2763. As a comparison, the US spends
almost twice that amount on health care per person.14
Regarding medication, there is increased focus on drug
consumption and corresponding expenses in the health ser-
682 nThe Annals of Pharmacotherapy n2007 April, Volume 41 www.theannals.com
H Herborg et al.
vice sector, as well as on patient safety, drug-related errors,
and adverse drug events. Danish and foreign studies esti-
mate that from 8% to 15% of all hospitalizations are drug
related, and studies of the hospitalization of elderly pa-
tients show that up to 31% are due to drug treatment.15-17
This is the reason that the Ministry of Interior and Health
decided to focus on rational pharmacotherapy and clinical
pharmacy. The Medicines Agency has set up a Department
of Rational Pharmacotherapy and, in addition, regional au-
thorities have hired drug consultants whose task targets the
prescription practices of physicians in primary care. A
number of initiatives have been carried out centrally to
help optimize drug treatment18:
1. personal electronic medication profile,
2. electronic patient journal (under construction),
3. national recommendation list,
4. national interaction database,
5. independent drug information for health professionals,
6. reporting system for errors and adverse drug events,
7. patient reporting of adverse effects,
8. Ordiprax, prescription statistics on national and re-
gional level, and
9. joint public health portal (www.sundhed.dk).
An interdisciplinary working group set up by the Min-
istry of Interior and Health has made recommendations for
the areas that may achieve health and/or economic benefits
from more extended use of clinical pharmacy in the prima-
ry and secondary sectors, as well as across the sectors. The
working group acknowledges that several studies have
proven that a number of clinical pharmacy services could
contribute to preventing or solving some of the drug-related
problems (DRPs). On this basis, it is recommended that the
evidence in practice be used to achieve a heightened quality
of patient treatment, thereby increasing patient safety.18
Community Pharmacy Services
Most services are obligatory and performed by every
community pharmacy.2The first obligation is to provide all
pharmacy-restricted drugs, regardless of whether they are
prescription-only or OTC. In practice, this means that the
pharmacy must have any medicine requested in stock or be
able to deliver it within 24 hours. Compounding is done in
very few pharmacies. Apart from pricing, labeling, and
checking prescriptions, there are a number of obligations
related to handling prescription-only medicine:
1. handling of extemporaneous preparations;
2. choosing the cheapest possible medicine;
3. checking dosage, indication, interactions, and con-
traindications;
4. providing basic information to customers on the use
of the drug;
5. reporting data to authorities for statistical and reim-
bursement purposes;
6. providing documentation for use of narcotics (de-
manded for crossing borders: a so-called medicine
passport);
7. receiving unused medicine from customers for de-
struction; and
8. providing information leaflets and access to an infor-
mation site for the public.
The pharmacies are also obliged to provide automated
dose dispensing of medicine (the drug for the individual
user is packed in unit doses with indications on when to
take the content of the bags), a service remunerated by the
state. All community pharmacies undertake regular quality
assessment based on the documentation required by legis-
lation, which is reviewed by inspectors from the Danish
Medicines Agency (service degree, waiting time, compe-
tence). Fifty percent of Danish pharmacies are certified un-
der the DS/EN ISO 9001:2000 quality management sys-
tem. This system is the Danish version of ISO 9001:2000,
an international standard that sets requirements for an or-
ganization’s quality management system.19 Certified phar-
macies are audited annually by an accredited certifying
body.They have goals for general as well as specialized
cognitive services, and they are required to performstaff
and customer satisfaction assessments and performance
evaluations.20
Apart from the services included in the fee and margin,
Danish pharmacies offer a number of other services, al-
though with varied frequency (Table 1).21
Each cognitive service is guided by a protocol on how
to deliver the service. The services can be provided by
pharmacists, as well as by pharmaconomists. Some payers
require that services be provided only by staffmembers
who have completed a course. The Ministry of Interior and
Health reimburses one of the services (inhalation counsel-
ing) via the agreed margin. Smoking cessation courses are
partially reimbursed by most regional authorities in Den-
mark. A large customer survey in 2003 showed that cus-
tomers are largely very satisfied with the pharmacies.22 On a
scale of 0–100, the satisfaction index is 82 and the loyalty
index is 78. Both indices increased compared with the previ-
ous survey in 2000 (by 2 points and 1 point, respectively),
despite the recent deregulation of OTC products.
Best Practices
Models for best practice have been developed and tested
in trials. Some of the models were later implemented more
broadly as part of the service offered by the pharmacies
(not reimbursed). Examples of such practice models are:
1. self-medication and self-care model combines re-
sponse to symptoms with advice on self-medication
and self-care,23 and
2. pharmaceutical care at the counter model is com-
prised of actively identifying, solving, and prevent-
Pharmaceutical Care in Denmark
The Annals of Pharmacotherapy n2007 April, Volume 41 n683
www.theannals.com
ing DRPs for customers with selected diagnoses (eg, asth-
ma, type 2 diabetes, angina pectoris, arthritis).24
Since 1999, the Pharmaceutical Association has dedi-
cated each year to a health-related theme, for example, dia-
betes, arthritis, and asthma. The Association provides cam-
paign and educational material on the theme for the phar-
macies, and most pharmacies participate actively. In 2004
and 2005, the topic was patient safety, which aimed to af-
firm the pharmacy as a key partner in avoiding errors and
injuries related to drug therapy.25 The Patient Safety Year
was planned as a campaign to place public focus on the
competence of the pharmacies and services related to pa-
tient safety.
Research in Community Pharmacy
Since the late 1970s, research in community pharmacy
has been conducted by the Section for Social Pharmacy
(SSP) at the DFU.26,27 Other actors in community pharma-
cy research are Pharmakon, professional organizations, re-
gional health administrations, and local pharmacies.5,28-33
The Pharmaceutical Association has been active in setting
up its own projects, as well as contributing to projects run
by other actors. Many of the actors involved in community
pharmacy research collaborate with other Danish research
organizations and universities interested in medicine use in
aresearch network called the Research Centre for Quality
in Medicine Use, based at the DFU. The center has been in
operation since 1999 and has made substantial contribu-
tions to interdisciplinary projects.
UNIVERSITY-BASED RESEARCH
The aim of the research by SSP at the DFU is to con-
tribute to a research basis for appropriate drug use. The re-
search is focused on medicine users and professionals in
the healthcare sector. The Section has several research
groups, including pharmacoepidemiology, cultures of
medicine, modern medicines, pharmacy practice, and
pharmaceutical policy, all of which contribute to commu-
nity pharmacy practice and beyond.
The research in medicine use and pharmacoepidemiolo-
gy has contributed to national surveys, as well as to more
practice-oriented projects. A research program on DRPs
has been set up in recent years, with the focus on the na-
ture, extent, and cost of DRPs in specific disease states.
SSP has a long-standing tradition of conducting research
relating to drug therapy from the user’sperspective.34-37 A
large part of this research has been developed with qualita-
tive methodology, and it has had major impact on pharma-
cist education and on community pharmacy.Most pharma-
cists will have conducted such studies on a small scale as
part of their education. In Denmark, this body of knowl-
edge has supported the shift from compliance to concor-
dance orientation. Concordance is considered the process
of prescribing and drug therapy based on partnership.38
Similarly, the development of pharmaceutical care pro-
grams has been influenced by this research from the start,
taking patient empowerment onboard as an integral part of
pharmaceutical care.39
Research involving the use of lifestyle drugs and pro-
jects on new consumer behavior have yielded new under-
standing of medicated normality as a social phenomenon
and of new consumers in community pharmacy.37,40,41
Research in pharmacy practice covers a broad range of
subjects. Toillustrate the scope, a list of current projects in
the pharmacy practice area from the Web site is provided
(Table 2).41
During the 1980s, researchers at SSP conducted studies
to investigate the pharmacist’s role perceptions and con-
ducted exploratory experimental research to develop new
professional activities and methods in the pharmacy.42-45
These projects were constructed from the pharmacist’s per-
spective and focused on individual and organizational
learning. Today, this work has developed into a body of
implementation research comprised of participatory action
research; studies in facilitators for implementing pharmacy
services in collaboration with researchers in Australia, Por-
tugal, and Spain; projects on pharmacy leadership; and,
684 nThe Annals of Pharmacotherapy n2007 April, Volume 41 www.theannals.com
H Herborg et al.
Table 1. Services Offered by Community Pharmacies
Number of
Pharmacies
Service (N = 322)
Blood pressure measurement and advice 152
Blood glucose measurement and advice 144
Breast pump rental 26
Cholesterol measurement and advice 45
Compression stockings (measurement and sale) 83
Falck HealthCare 27
Inhalation counseling 219
Inspection of emergency physician kit 50
Inspection of ships’ medicine chests 56
Instruction in self measurement of blood glucose 128
Carbon monoxide measurement 97
Fat percentage measurement 31
Medication review—Brown bag 82
Medication review—Check on your medicine 85
Medication review—Nursing home and home care 71
Meetings for groups of new mothers 28
Peak flow measurement 74
Quality assurance of medicine handling at nursing 40
homes and in home care
Skin type test 18
Slimming counseling (groups) 51
Slimming counseling (individual) 57
Smoking cessation (groups) 123
Smoking cessation (individual) 148
Smoking cessation (screening) 46
Supplying medicine chests 44
Training nursing staff 92
most recently, evaluation of the first reimbursed cognitive
service.46
The Pharmacy-University Study has been a large 3 year
program using research as a learning, research, and imple-
mentation strategy for dealing with DRPs in collaboration
among researchers, students, and practitioners. This project
has contributed a platform for disseminating knowledge
about pharmaceutical care among students and practition-
ers.47-50
SSP has been involved in health technology assess-
ments of services and technology in community pharmacy,
with particular focus on software for detecting drug inter-
actions and, most recently, automated drug dispensing us-
ing Social Construction of Technology Theory as an alter-
native theoretical approach to Health Technology Assess-
ment.51,52
Policy research has recently come into focus, with an
evaluation of the liberalization of the Icelandic pharmacy
system as a major contribution.53,54 This type of research
has brought the processes of professionalization and depro-
fessionalization back into focus. The contract between com-
munity pharmacy and society has been analyzed in a recently
finished doctoral dissertation on the liberalization of part of
the Danish OTC market to a new general sales list.55
RESEARCH AT PHARMAKON
Since 1993, the Research and Development division at
Pharmakon has conducted research in pharmacy practice
and has developed methods, tools, and quality standards
for new community pharmacy services. The strategic goal
is to contribute to and document the social value of com-
munity pharmacy.The research has been based on the
WHO/International Pharmaceutical Federation guidelines
for Good Pharmacy Practice.56
The first Danish study on pharmaceutical care had ma-
jor results. Conducted in the mid-1990s in collaboration
with Charles D Hepler’s team at the University of Florida,
and later also with the European Asthma Therapeutic Out-
comes Monitoring studies under the framework of Phar-
maceutical Care Network Europe (PCNE), the study was
coordinated by the Danish team.39,57 PCNE was founded as
aresult of this collaboration. The program developed a dis-
ease-specific pharmaceutical care model with strong em-
phasis on the user’s perspective. The program had positive
impact on knowledge, inhalation errors, drug prescribing
and health outcomes, and use of healthcare resources. The
project also resulted in further research and development
of a number of cognitive services for asthma patients, one
of which, inhalation counseling, has been reimbursed by
the government since 2004.58,59
The research program Improving Drug Therapy for the
Elderly developed and tested a generic pharmaceutical
care model for a specific patient group: elderly polyphar-
macy patients. It was conducted in collaboration with 7
countries.60,61 This project has been the basis for the devel-
opment of community pharmacy services for the elderly
and nursing homes, and these models have been tested in
small research projects.62-64
Dose dispensing has been studied at various times at the
DFU and at Pharmakon.31 Lately, the system has been
evaluated in the previously mentioned health technology
assessment in collaboration with the University of South-
ern Denmark.52,65
Another major project has been Improving Self-Medi-
cation and Self-Care. It has demonstrated that pharmacies
can implement evidence-based protocols for responding to
symptoms and advising on self-care and drug use for mi-
nor ailments such as hay fever and dyspepsia, and achieve
positive patient/user outcomes.66
As research continues to document high value for rigor-
ous best practice methods, the problem of implementation
of such methods is growing. However, the implementation
rate of pharmaceutical care activities in Danish pharmacies
is low.67 Traditional mechanisms such as courses and quali-
ty manuals with protocols have not worked sufficiently.
There are several barriers to implementation. A number of
barriers were identified in research projects:
1. collaboration in the healthcare sector;
2. physical surroundings, technology;
3. customer perceptions, people’s attitudes;
4. program content and tools;
5. internal organization at the pharmacy;
6. knowledge and practical skills;
7. personal perceptions;
8. legislation, society; and
9. finances, resources.61,66
Since 1993, Pharmakon has conducted research in im-
plementation and organizational change. The program,
Pharmaceutical Care in Denmark
The Annals of Pharmacotherapy n2007 April, Volume 41 n685
www.theannals.com
Table 2. Current Projects41
Indicators of good pharmacy practice
Leadership and organization in pharmacy practice
Health technology assessment of automated dose dispensing in
the primary healthcare sector
Professional development of pharmacy practice, with special focus
on implementation processes
Impact on health economy of preventable drug-related morbidity and
selected drug-related morbidity interventions
Distribution of medicine in Denmark in light of deregulation
Developing a new method for smoker addiction evaluation
Status of pharmaceutical care in Danish community pharmacies
The Pharmacy University study: participatory action research as
an implementation strategy for development of pharmacy practice
Improved self-medication and self-care: a controlled study
Sociology and pharmacy practice research
The pharmacy profession: a sociological perspective
The Counselling Pharmacy, is an example of this ap-
proach.68
In recent years, Pharmakon has conducted research on
medication safety in primary care, in collaboration with
The Society for Patient Safety and the Pharmaceutical As-
sociation. Their research shows that community pharma-
cies prevent many errors (23 prescription interventions in
10 000 prescriptions) and make few dispensing errors (one
error per 10 000 prescriptions).69
Finally, since 2001, Pharmakon has developed and operat-
ed The Danish Pharmacy Practice Evidence Database. The
database is comprised of literature reviews compiled in evi-
dence reports in key pharmacy practice areas, with emphasis
on primary care. It is based on literature in English and Scan-
dinavian languages. References and summaries in English
can be accessed at www.pharmakon.com.
Funding
Until 2005, community pharmacy research had a strong
funding base in The Pharmacy Foundation of 1991. The
Danish Pharmaceutical Association has also been active,
particularly through its ownership of Pharmakon and by
funding projects and the evidence database. The Pharmacy
Foundation cofunded The Centre for Quality in Medicine
Use, the majority of the large-scale projects mentioned in
this article, and many of the small projects as well. This
has been the primary financial source, together with basic
university funds, PhD grants, and basic Pharmakon funds.
The Pharmacy Foundation no longer exists, and funding
now is primarily obtained from basic research budgets.
However, the Danish Ministry of the Interior and Health
and the National Board of Health have launched practice-
oriented research programs with specific focus on drug use
or disease states (eg, diabetes). Some community pharma-
cy projects have managed to attract funds from these pro-
grams.
Plans for the Next Five Years
At present there are no known plans for new pharmacy
services at state, national, or private insurance levels. Start-
ing in 2007, a general structural reform will shift responsi-
bility for a major part of primary health care from regional
authorities to large local authorities (hospitals will still be
operated at regional level but financed by state funds). The
reform will create new incentives for the local authorities,
as they will be paying for the health care of their citizens.
As payers, these local authorities will save money by pre-
venting illness and hospitalizations. This may mean new
opportunities for community pharmacy.There are plans to
build new local healthcare centers with a strong focus on
prevention and rehabilitation. In pilot projects, some of
these new centers have shown interest in pharmacy ser-
vices such as medication review and medicines manage-
ment. A few local authorities have already made prelimi-
nary contracts with pharmacies regarding nursing home
services.
The Pharmaceutical Association has a clear vision of
shifting the core of community pharmacy services from lo-
gistic to cognitive and clinical activities. The professional
strategy is to use the competence of the pharmacy to take
coresponsibility for the drug treatment of the customer and
for patient safety. The Association aims for more govern-
ment remuneration for services (eg, medication reviews) and
also targets the new local authorities. Both employee associa-
tions are active in promoting clinical pharmacy services in
primary care, which was also the focus of the Pharmaceutical
Association’s campaign in 2006. There are plans to develop
the quality system and provide more documentation on the
pharmacy sector level, but no details are known as yet.
The DFU and Pharmakon have plans for curriculum
changes. A reform of the community pharmacy apprentice-
ship for pharmacy students will change the evaluation cri-
teria and provide more emphasis on communication and
pharmaceutical care. For pharmaconomists, there will be
more theory and a reinforcement of e-learning support dur-
ing trainee periods.
SSP,the Pharmaceutical Association, and Pharmakon
are drawing up plans to create a research consortium. Joint
research projects running at present are:
1. implementing drug therapy—improving adherence
and self-management among users of antihyperten-
sives;
2. safe and effective use of drugs used in treatment of
type 2 diabetes; and
3. better use of medicines in home care and nursing
homes.
All of these projects aim to implement collaborative pri-
mary care models with a focus on community pharmacy’s
contribution to the medication process and the patient’s
journey between levels of care. This objective reflects a
strong trend in current community pharmacy research.
Summary
Denmark has few but large community pharmacies and
along tradition of research and development resulting in
several well documented cognitive and clinical services.
However, few services are reimbursed and implementation
is still a challenge.
Hanne Herborg MSc (pharm), Director, Research and Develop-
ment Division, Pharmakon a/s, Danish College of Pharmacy Practice,
Hillerød, Denmark
Ellen Westh Sørensen MSc (pharm), Associate Professor, De-
partment of Pharmacology and Pharmacotherapy, Section for So-
cial Pharmacy and Research Centre for Quality in Medicine Use,
The Danish University of Pharmaceutical Sciences, Copenhagen,
Denmark
686 nThe Annals of Pharmacotherapy n2007 April, Volume 41 www.theannals.com
H Herborg et al.
Bente Frøkjær MSc (pharm), Project Coordinator, Research and
Development Division, Pharmakon a/s, Danish College of Pharma-
cy Practice
Reprints: Dr. Frøkjær, Research and Development Division, Phar-
makon a/s, Danish College of Pharmacy Practice, Milnersvej 42,
DK-3400, Hillerød, Denmark, fax 45 4820 6060, bf@pharmakon.dk
References
1. Annual Report 2005-2006, key figures 2005, Danish Pharmaceutical As-
sociation.
2. Bekendtgørelse af lov om apoteksvirksomhed. LBK nr. 657 af 28/07/1995
med senere ændringer [Danish Act on Pharmacy Practice, Order no. 657
of 28 July 1995 with later amendments].
3. Danmarks Farmaceutiske Universitet, Efter- og videreuddannelse, forår
2007 [Danish University of Pharmaceutical Sciences, Continuing Educa-
tion Program, Spring 2007]. www.dfuni.dk/index.php?id = 975 (ac-
cessed 2006 Nov 7).
4. Danmarks Farmaceutiske Universitet, Master of Drug Management
(MDM) [Danish University of Pharmaceutical Sciences, Master of
Drug Management (MDM)]. www.dfuni.dk/index.php/Master-of-Drug-
Management/1125/0/ (accessed 2006 Nov 15).
5. Pharmakon College. www.pharmakon.com/asp/english_menu.asp?pageid
=318 (accessed 2006 Nov 15).
6. Annual report 2005, Pharmakon.
7. OECD health data file, 2004.
8. Lægemiddelstyrelsen: Generel statistik om lægemiddelsalget 2001–2005
[Danish Medicines Agency, general statistics on sales of medicinal products
2001–2005]. www.laegemiddelstyrelsen.dk/db/filarkiv/6050/Tab3.pdf (ac-
cessed 2006 Nov 14).
9. WHO Collaborating Centre for Drug Statistics Methodology, About the
ATC/DDD system. www.whocc.no/atcddd/atcsystem.html#6 (accessed
2007 Jan 6).
10. Lov nr. 311 af 9/6 1971 om offentlig sygesikring, jf. lovbekendtgørelse
nr. 509 af 1/7 1998 med senere ændringer [Act no. 311 of 9 June 1971
on the Danish National Health Service, see Order no. 509 of 1 July 1998
with later amendments].
11. Danmark sygeforsikring, English summary. www.sygeforsikring.dk/
Default.aspx?ID = 229 (accessed 2006 Nov 22).
12. Bekendtgørelse nr. 1215 af 7. december 2005 om apoteker og apoteks-
personale, Lægemiddelstyrelsen [Order no. 1215 of 7 December 2005 on
Pharmacists and Pharmacy Personnel, Danish Medicines Agency].
13. Sundhedsloven, Lov nr 546 af 24/06 2005 [Danish Act on National
Health Service no. 546 of 24 June 2005].
14. Sundhedssektoren i tal 2006 [The health sector in figures 2006].
www.im.dk/publikationer/sundhedssektoren_i_tal/samletjan06.htm (ac-
cessed 2006 Nov 7).
15. Hallas J, Gram L, Grodum E, et al. Drug related admissions to medical
wards: a population based survey.Br J Clin Pharmacol 1992;33:61-8.
16. Lazarou J, Pomeranz BH, Corey PN. Incidence of adverse drug reactions
in hospitalized patients: a meta-analysis of prospective studies. JAMA
1998;279:1200-5.
17. Hallas J, Worm J, Beck-Nielsen J, et al. Drug related events and drug
utilisation in patients admitted to geriatric hospital department. Danish
Med Bull 1991;38:417-20.
18. Brug medicinen bedre—Perspektiver i klinisk farmaci. Rapport fra
Lægemiddelstyrelsens arbejdsgruppe om klinisk farmaci juni 2004 [Use
medicine better—perspectives in clinical pharmacy. Report from the
working group on clinical pharmacy,Danish Medicines Agency,June
2004].
19. International Organization for Standardisation, Understanding the basics.
www.iso.org/iso/en/iso9000-14000/understand/inbrief.html (accessed
2007 Jan 6).
20. Lægemiddelstyrelsens bekendtgørelse nr.1235 af 17/12/2002 om ser-
vicemål for apotekers distributionsopgaver og faglige rådgivning og in-
formation [Danish Medicines Agency Order no. 1235 of 17 December
2002 on service objectives for pharmacies’ distribution service and pro-
fessional advice and information].
21. Information from the Danish Pharmaceutical Association on 15 Febru-
ary 2006.
22. Thorsted CK. Apotekerne har tilfredse kunder [The pharmacies have sat-
isfied customers]. Farmaci 2003;160:11-9.
23. Hansen HW, Lessow B, Nielsen GH, et al.The counselling pharmacy.
Abstracts 2001, World Congress of Pharmacy and Pharmaceutical Sci-
ences 2001:94.
24. Kofod S. Pharmaceutical care at the counter. Abstracts 2002, World
Congress of Pharmacy and Pharmaceutical Sciences 2002:82.
25. Jacobsgaard H, Riise M, Nørregaard G, Fonnesbæk L, Herborg H,
Oldam T. Patient Safety Year 2004. Abstracts 2004, World Congress of
Pharmacy and Pharmaceutical Sciences 2004:50.
26. Danmarks Farmaceutiske Universitet, Institut for Farmakologi og Far-
makoterapi, Forskning [Danish University of Pharmaceutical Sciences,
Department of Pharmacology and Pharmacotherapy, Research] www.dfuni.
dk/index.php/Samfundsfarmaci/2760/0/ (accessed 2006 Nov 3).
27. Danish University of Pharmaceutical Sciences. www.dfh.dk/uk/ (ac-
cessed 2006 Nov 7).
28. Thorup AB, Mogensen I. Farmaceutisk omsorg til type-2 diabetikere
[Pharmaceutical care for type 2 diabetics. Report, Danish Pharmaceuti-
cal Association]. Rapport, Danmarks Apotekerforening, 1997.
29. Rechnagel V. Healthcare check service at the pharmacy. Abstracts 2000,
World Congress of Pharmacy and Pharmaceutical Sciences 2000:88.
30. Medicingennemgang Få styr på medicinen—med hovedvægt på
substitutionsproblematikken. Projekt udført i Århus Amt for Århus Amts
Apotekerforening, 2006. [Medication review: Medication under con-
trol—main focus on substitution. Project in Århus County commissioned
by Århus County Pharmaceutical Association. Report]. Rapport 2006.
31. Tomsen DV,Søndergaard B, Damsgaard TM, HerborgH. Dosisdis-
pensering—et forsøg i Vejle Amt [Dose dispensing—a project in Vejle
County. Evaluation report]. Evalueringsrapport, 1999.
32. Dinsen C, Kirkeby B, Kjellberg J, et al. Klinisk farmaceut i primærsek-
toren. Et udviklingsprojekt i Frederiksborg Amt [Clinical pharmacist in
primary sector. A development project in Frederiksborg County. Report].
Rapport Frederiksborg Amt 2004.
33. Nordjyllands Amt: Medicingennemgang for polyfarmacipatienter i Aal-
borg—et pilotprojekt. [Medication review for polypharmacy patients in
Aalborg—a pilot project. Report] Rapport 2005.
34. Holstein BE, Hansen EH, Due P, Almarsdottir AB. Self-reported
medicine use among 11-to 15-year-old girls and boys in Denmark 1988–
1998. Scand J Public Health 2003;31:334- 41.
35. Knudsen P, Hansen EH, Eskildsen K. Leading ordinary lives: a qualita-
tive study of younger women’s perceived functions of antidepressants.
Pharm World Sci 2003;25:162-7.
36. Knudsen P, Hansen EH, Traulsen JM. Perceptions of young women using
SSRI antidepressants—a reclassification of stigma. Int J Pharm Pract 2002;
10:243-52.
37. Traulsen JM, Nørreslet M. The new consumer of medicine—the phar-
macy technicians’ perspective. Pharm World Sci 2004;26:203-7.
38. National Prescribing Centre. What is concordance? www.npc.co.uk/
med_partnership/about-us/concordance.html (accessed 2007 Jan 6).
39. Herborg H, Soendergaard B, Froekjaer B, et al. Improving drug therapy
for patients with asthma. Part 1: patient outcomes. J Am Pharm Assoc
2001;41:539-50.
40. Møldrup C. The use of the terms “lifestyle medicines” or “lifestyle
drugs.” PharmWorld Sci 2004;26:193-6.
41. Danish University of Pharmaceutical Sciences, Department of Pharma-
cology and Pharmacotherapy. Pharmacy practice—current projects.
www.farma.ku.dk /index.php/Pharmacy-practice/634/0/ (accessed 2006
Nov 7).
42. Sørensen EW. The pharmacists professional self-perception. J Soc Ad-
min Pharm 1986;4:144-56.
43. Kallesen E, Lyon G. Huskeliste—medicin og ældre på Østerbro [Notes—
medicine and the elderly at Osterbro]. Farmaci 1993;150:102-5.
44. Sørensen EW.Implementering af farmaceutisk omsorgiskranken på
Brønshøj Apotek. Del III: Så langt nåede Brønshøj Apotek med reg-
istreringen af lægemiddelrelaterede problemer [Implementation of phar-
Pharmaceutical Care in Denmark
The Annals of Pharmacotherapy n2007 April, Volume 41 n687
www.theannals.com
maceutical care at the counter at Bronshoj pharmacy. Part III: Status for
registration of drug-related problems. Report]. Rapport Danmarks Far-
maceutiske Universitet 1999.
45. Børsting I, Nielsen JCR, Sørensen EW. Apotek på en anden måde.
[Pharmacy in a new way]. Nyt fra Samfundsvidenskaberne 1989.
46. Hopp T, Sørensen EW, Herborg H, Roberts AS. Implementation of cog-
nitive pharmaceutical services in professionally active pharmacies. Int J
Pharm Pract 2005;13:21-31.
47. Sørensen EW, Haugbølle LS, Herborg H, Tomsen D. Improving situated
learning in pharmacy internship. Pharm Educ 2005;5:223-33.
48. Nørgaard LS, Sørensen EW, Gundersen B, Lorentzen L, Petersen KH.
Basing pharmacy counselling on the perspective of the angina pectoris
patient. Pharm World Sci 2002;24:71-8.
49. Nørgaard LS, Sørensen EW, Henriksen HH. Medication- and illness-re-
lated factual knowledge, perceptions and behaviour in angina pectoris
patients. Patient Educ Counsel 2002;47:281-9.
50. Sørensen EW, Haugbølle LS. Apotek-Højskole projektet, Angina Pec-
toris patienten og apoteket [The pharmacy-university project, the angina
pectoris patient and the pharmacy]. Danmarks Farmaceutiske Universitet
2003.
51. Nørgaard L, Sørensen EW, Morgall JM. Social constructivist analysis of
apatient medication record experiment—why a good idea and good in-
tentions are not enough. Int J Pharm Pract 2000;8:237- 46.
52. Lee A, Gundgaard J, Haugbølle L, Herborg H, Søndergaard B, Sinding
LS. Maskinel Dosisdispensering—en ny teknologi i det danske sund-
hedsvæsen [Dose dispensing—new technology in the Danish healthcare
sector]. Månedsskrift for Praktisk Lægegerning 2006;84:735- 45.
53. Almarsdóttir A, Björnsdóttir I, Traulsen JM. Pharmacists in a liberalised
system result from a profession-wide survey in Iceland. Int J Pharm
Pract 2002;10:47-53.
54. Almarsdottir A, Morgall J M, Grimsson A. Cost containment of pharma-
ceutical use in Iceland: the impact of liberalisation and user charges. J
Health Serv Res Policy 2000;5:109-13.
55. Bjerg Larsen J. Lægemiddeldistribution i Danmark—set i lyset af dereg-
ulering [Drug distribution in Denmark—in perspective of deregulation].
Danmarks Farmaceutiske Universitet, 2004.
56. The Tokyo Declaration (1993). Standards for quality of pharmacy ser-
vices (FIP Guidelines for Good Pharmacy Practice, September 1993)
and revised version FIP/WHO GPP (1997).
57. HerborgH, Soendergaard B, Jorgensen T, Fonnesbaek L, Hepler CD,
Holst H. Improving drug therapy for patients with asthma. Part 2: Use of
antiasthma medications. J Am PharmAssoc 2001;41:551-9.
58. Klinke B, Fonnesbæk L. Tjek på inhalation—afprøvning af ydelsen [In-
halation counselling—pilot test of the service. Evaluation report]. Eval-
ueringsrapport Danmarks Farmaceutiske Universitet og Pharmakon 2005.
59. Kaarill L, Børsting A, Dyssegaard A, Fonnesbæk L. Inhalation technique
assessment. The first health service in Danish pharmacies reimbursed by
the government. Abstracts 2000, World Congress of Pharmacy and Phar-
maceutical Sciences 2005:98.
60. Bernsten C, Bjsörkman I, Caramona M, et al. Improving the well-being
of elderly patients via community pharmacy-based provision of pharma-
ceutical care. Drugs & Aging 2001;18:63-77.
61. Søndergaard B, Herborg H, Jörgensen T, et al. Forebyggelse af lægemid-
delrelaterede problemer gennem Apotekets Ældre Service. Et forsøgs-
projekt på danske apoteker 1996–1999 [Prevention of drug-related prob-
lems via pharmacy based elderly service. A pharmacy project 1996 –
1999. Report]. Rapport 2001.
62. Pultz K, Salout M. Ydelsen ‘Medicingennemgang på plejehjem og i
hjemmeplejen’ afprøvet på 5 plejehjem [The service: ‘Medication re-
view at nursing homes and in home care’ tested at 5 nursing homes.
Evaluation report]. Evalueringsrapport, Pharmakon og Danmarks
Apotekerforening 2005.
63. Pultz K, Salout M. Ydelsen ‘Medicingennemgang for ældre’ afprøvet på
5apoteker [The service: ‘Medication review for elderly’ tested at 5 phar-
macies. Evaluation report]. Evalueringsrapport, Pharmakon og Dan-
marks Apotekerforening 2005.
64. Pultz K, Søndergaard B, Herborg H. Farmaceutisk rådgivning til pleje-
hjem [Pharmaceutical counselling at nursing homes. Evaluation report].
Evalueringsrapport, Pharmakon 2003.
65. Sørensen J, Gundgaard J, Haugbølle LS, Herborg H, Lee A, Rossing C.
Maskinel dosisdispensering i primærsektoren: Elementer af en medicin-
sk teknologivurdering [Dose dispensing in the primary sector. Elements
of health technology assessment. Final report]. Sammenfattende rapport.
Syddansk Universitet, Danmarks Farmaceutiske Universitet og Phar-
makon 2005.
66. Tomsen D, Søndergaard B, Herborg, H, Klinke BO. Forbedret
selvmedicinering og egenomsorg [Improved self-medication and self-
care. Working report]. Arbejdsrapport, Pharmakon 2004.
67. Rossing C. The practice of pharmaceutical care in Denmark—a quantita-
tive approach. Thesis, The Danish University of Pharmaceutical Sci-
ences, Department of Social Pharmacy, 2003.
68. Herborg H, Fonnesbæk L, Frøkjær B, Søndergaard B. The Counselling
Pharmacy. Abstracts 2002, World Congress of Pharmacy and Pharma-
ceutical Sciences 2002:85.
69. Knudsen P, Herborg H, Knudsen M, Mortensen AR, Hellebek A.
Apotekets forebyggelse af fejl. Kortlægning og aggregerede kerneår-
sagsanalyser [Prevention of errors at the pharmacy. Survey and aggregat-
ed root cause analysis. Technical report]. Teknisk rapport. Pharmakon
2005.
EXTRACTO
OBJETIVO: Evaluar el estado actual de la comunidad farmacéutica en
Dinamarca en cuanto a la práctica e investigación y discutir la tendencia
futura.
HALLAZGOS: Dinamarca tiene un sistema de bienestar social que provee
cuidado de salud, servicio social y pensión. El cuidado médico y
quirúrgico son gratis. La prescripción de medicamentos son
reembolsable en un promedio de 56%. Las comunidades farmacéuticas
son propiedades privadas pero las autoridades de salud regulan los
precios de los medicamentos y el número de farmacias. Hasta el
presente, Dinamarca tiene 322 farmacias en una relación de una por
cada 16700 habitantes. Todas las farmacias proveen medicamentos
recetados, medicamentos autorizados sin receta médica, consejería
acerca del uso de medicamentos, dosis, substición de genérico y la
administración de reembolso individual para los pacientes registrado.
Todas las mezlas de medicamentos están centralizadas en 3 farmacias a
excepción de las preparaciones simples. Muchas farmacias ofrecen el
servicio de medir los niveles de ázucar y colesterol en sangre, presión
sanguínea y en un 60% de las farmacias, se ofrece consejería sobre
inhaladores en un servicio de reembolso. La investigación en la práctica
de farmacia eatán bien establecida y se conduce, principalmente, en las
universidades y en Pharmakon A/S, cuyo dueño es la Asociación
Farmacéutica Dinamarqués.
DISCUSION: Los servicios extendidos en farmacia clínica son una
prioridad de todas las organizaciones farmacéuticas en Dinamarca. El
reembolso es tratado a nivel nacional como también los pagadores en la
nueva estructura de la autoridad local de Dinamarca. La tendencia en la
investigación se enfoca en cuidado de salud colaborativo, desarrollo y
documentación del valor de los servicios de farmacia de comunidad; asi
como, perfeccionar servicios y fortalecer la implementación.
CONCLUSION: Dinamarca tiene pocas pero amplias farmacias de
comunidad y una larga tradición investigación y desarrollo resultando en
algunos servicios cognoscitivos y clínicos bien documentados. Sin
embargo; pocos servicios son reembolsados y la implementación es
todavía un reto.
Wilma M Guzmán-Santos
RÉSUMÉ
OBJECTIF: Revoir le statut de la pratique et de la recherche en pharmacie
communautaire au Danemark et présenter les tendances futures.
688 nThe Annals of Pharmacotherapy n2007 April, Volume 41 www.theannals.com
H Herborg et al.
RÉSUMÉ: LeDanemark a un système social qui procure des soins de
santé, des services sociaux, et de pension à sa population. L’achat de
médicaments sur prescription est remboursé par l’état à raison de 56%.
Les pharmacies communautaires sont privées mais les autorités
gouvernementales règlementent le prix des médicaments et le nombre
de pharmacies. Actuellement, le Danemark a 322 pharmacies,
correspondant à environ 1 pharmacie par 16 700 habitants. Toutes les
pharmacies vendent des médicaments de vente libre et d’ordonnance,
donnent des conseils sur l’utilisation optimale des médicaments,
favorisent la substitution générique, et maintiennent un registre des
remboursements. A l’exception de préparations simples, les préparations
magistrales sont fabriquées centralement dans 3 pharmacies. Beaucoup
de pharmacies offrent la prise de mesure de la tension artérielle, des
glycémies, et du cholestérol, et 60% conseillent leurs patients sur les
techniques d’inhalation, service remboursé par le système social. La
recherche en pratique pharmaceutique est bien établie et se conduit
principalement dans les universités et chez Pharmakon A/S, compagnie
appartenant à l’association pharmaceutique danoise.
DISCUSSION: Les services élargis de pharmacie clinique sont prioritaires
auprès des organisations pharmaceutiques danoises. Le remboursement
est discuté au niveau national ainsi qu’au niveau des payeurs au sein de
nouvelles structures locales. Les tendances au niveau de la recherche
visent les soins de santé en collaboration, le développement et la
documentation de la valeur des services cliniques communautaires,
l’optimisation des services, et une implantation renforcée.
CONCLUSIONS: Le Danemark a quelques grandes pharmacies
communautaires et une longue tradition de recherche et de
développement résultant en des services cliniques cognitifs bien
documentés. Cependant, peu sont remboursés et leur implantation
demeure difficile.
Marc M Perreault
Pharmaceutical Care in Denmark
The Annals of Pharmacotherapy n2007 April, Volume 41 n689
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