Evaluation of studies investigating the effectiveness of pharmacists' clinical services

Role of Clinical Pharmacist in a Heart Failure Clinic

Purpose

To determine if the inclusion of a clinical pharmacist (CP) in a heart failure (HF) multidisciplinary team could lead to a reduction in the number of hospital admissions and additionally decrease the clinical signs and symptoms of HF patients with either Medicaid or no medical insurance.

Methods

Longitudinal study to determine the impact of a pharmaceutical-care service program to HF patients by comparing the 9-month period before (pre-intervention) and the 9-month period after (post-intervention) implementation of the program. The intervention of the CP was directed in two complementary functions. The first was direct patient contact and the second was to provide drug information to the medical clinicians.

Results

Twenty-nine outpatients completed the study. Over 9 months, the CP made a total of 216 interventions and had three in-person, follow-up contacts and three telephone contacts per patient. At post-intervention, there was a statistically significant reduction in the total number of hospitalizations (50 vs 23; P < 0.018) and length of stay (LOS) (263 days vs 108 days; P < 0.03). However, there was an insignificant reduction in HF hospitalizations, LOS, and total number of HF signs and symptoms.

Conclusions

Addition of a CP to an outpatient HF clinic can lead to fewer hospital admissions and a reduction in the LOS in patients with either Medicaid or no medical insurance.

The Effect of Medication Reviews in a Rural Community Pharmacy Assistance Program: The Cenla Medication Access Program

The purpose of this article is to determine the effect of mediing equations were used to assess change in PURPOSE, USE,cation reviews on patient understanding of and compliance COMPLIANCE, INTERACTION, and REACTION over time. to medications for participants in the Cenla Medication Ac All effects were adjusted for differences in age, race, gender, cess Program (CMAP). A sample of 844 individuals with a to the number of years of education, total number of medicatal of 2013 reviews over a period of 6 months to 1 year protions per patient, and the patient’s primary diagnosis. Signifiduced 5 outcome variables: the percentage of the total cant increases were observed for PURPOSE, USE, and number of drugs the patient understands the purpose of COMPLIANCE. A significant decrease was observed for (PURPOSE), understands the proper use of (USE), and is INTERACTION. No significant difference in REACTION was compliant with (COMPLIANCE) and the percentage of paobserved over time. CMAP has seen increases in patient untients that experienced any drug-drug or drug-disease interderstanding and compliance, as well as a decrease in drug-actions (INTERACTION) or any adverse reactions drug and drug-disease interactions through the first year of (REACTION). Mixed-effects models and generalized estimat medication reviews.

Comply With Us: Improving Medication Adherence

Medication noncompliance is a pervasive problem resulting in significant morbidity and mortality. There are many terms used to describe medication-taking behavior including compliance, adherence, intelligent compliance, and drug forgiveness. More recently, clinicians have focused on the need for a collaborative partnership with patients to attain medication adherence. Problems identified include the patient’s failing to initiate therapy, under using or overusing a drug, stopping a drug too soon, and mistiming or skipping doses. Adherence to medications is a complex health behavior. There are many risk factors associated with decreased compliance, and many strategies have been shown to improve drug-taking behavior and patient outcomes. By careful assessment, the pharmacist can identify the high-risk patient, recommend an individualized care plan, and provide the follow-up necessary to successfully change patient behavior. Pharmacists should focus on improving their own application of behavior modification principles and patient communication skills. Improved medication compliance results in improved humanistic, clinical, and economic outcomes.

Interventions to improve safe and effective medicines use by consumers: an overview of systematic reviews

BACKGROUND

Many systematic reviews exist on interventions to improve safe and effective medicines use by consumers, but research is distributed across diseases, populations and settings. The scope and focus of such reviews also vary widely, creating challenges for decision-makers seeking to inform decisions by using the evidence on consumers' medicines use.This is an update of a 2011 overview of systematic reviews, which synthesises the evidence, irrespective of disease, medicine type, population or setting, on the effectiveness of interventions to improve consumers' medicines use.

OBJECTIVES

To assess the effects of interventions which target healthcare consumers to promote safe and effective medicines use, by synthesising review-level evidence.

SEARCH METHODS

We included systematic reviews published on the Cochrane Database of Systematic Reviews and the Database of Abstracts of Reviews of Effects. We identified relevant reviews by handsearching databases from their start dates to March 2012.

SELECTION CRITERIA

We screened and ranked reviews based on relevance to consumers' medicines use, using criteria developed for this overview.

DATA COLLECTION AND ANALYSIS

We used standardised forms to extract data, and assessed reviews for methodological quality using the AMSTAR tool. We used standardised language to summarise results within and across reviews; and gave bottom-line statements about intervention effectiveness. Two review authors screened and selected reviews, and extracted and analysed data. We used a taxonomy of interventions to categorise reviews and guide syntheses.

MAIN RESULTS

We included 75 systematic reviews of varied methodological quality. Reviews assessed interventions with diverse aims including support for behaviour change, risk minimisation and skills acquisition. No reviews aimed to promote systems-level consumer participation in medicines-related activities. Medicines adherence was the most frequently-reported outcome, but others such as knowledge, clinical and service-use outcomes were also reported. Adverse events were less commonly identified, while those associated with the interventions themselves, or costs, were rarely reported.Looking across reviews, for most outcomes, medicines self-monitoring and self-management programmes appear generally effective to improve medicines use, adherence, adverse events and clinical outcomes; and to reduce mortality in people self-managing antithrombotic therapy. However, some participants were unable to complete these interventions, suggesting they may not be suitable for everyone.Other promising interventions to improve adherence and other key medicines-use outcomes, which require further investigation to be more certain of their effects, include:· simplified dosing regimens: with positive effects on adherence;· interventions involving pharmacists in medicines management, such as medicines reviews (with positive effects on adherence and use, medicines problems and clinical outcomes) and pharmaceutical care services (consultation between pharmacist and patient to resolve medicines problems, develop a care plan and provide follow-up; with positive effects on adherence and knowledge).Several other strategies showed some positive effects, particularly relating to adherence, and other outcomes, but their effects were less consistent overall and so need further study. These included:· delayed antibiotic prescriptions: effective to decrease antibiotic use but with mixed effects on clinical outcomes, adverse effects and satisfaction;· practical strategies like reminders, cues and/or organisers, reminder packaging and material incentives: with positive, although somewhat mixed effects on adherence;· education delivered with self-management skills training, counselling, support, training or enhanced follow-up; information and counselling delivered together; or education/information as part of pharmacist-delivered packages of care: with positive effects on adherence, medicines use, clinical outcomes and knowledge, but with mixed effects in some studies;· financial incentives: with positive, but mixed, effects on adherence.Several strategies also showed promise in promoting immunisation uptake, but require further study to be more certain of their effects. These included organisational interventions; reminders and recall; financial incentives; home visits; free vaccination; lay health worker interventions; and facilitators working with physicians to promote immunisation uptake. Education and/or information strategies also showed some positive but even less consistent effects on immunisation uptake, and need further assessment of effectiveness and investigation of heterogeneity.There are many different potential pathways through which consumers' use of medicines could be targeted to improve outcomes, and simple interventions may be as effective as complex strategies. However, no single intervention assessed was effective to improve all medicines-use outcomes across all diseases, medicines, populations or settings.Even where interventions showed promise, the assembled evidence often only provided part of the picture: for example, simplified dosing regimens seem effective for improving adherence, but there is not yet sufficient information to identify an optimal regimen.In some instances interventions appear ineffective: for example, the evidence suggests that directly observed therapy may be generally ineffective for improving treatment completion, adherence or clinical outcomes.In other cases, interventions may have variable effects across outcomes. As an example, strategies providing information or education as single interventions appear ineffective to improve medicines adherence or clinical outcomes, but may be effective to improve knowledge; an important outcome for promoting consumers' informed medicines choices.Despite a doubling in the number of reviews included in this updated overview, uncertainty still exists about the effectiveness of many interventions, and the evidence on what works remains sparse for several populations, including children and young people, carers, and people with multimorbidity.

AUTHORS' CONCLUSIONS

This overview presents evidence from 75 reviews that have synthesised trials and other studies evaluating the effects of interventions to improve consumers' medicines use.Systematically assembling the evidence across reviews allows identification of effective or promising interventions to improve consumers' medicines use, as well as those for which the evidence indicates ineffectiveness or uncertainty.Decision makers faced with implementing interventions to improve consumers' medicines use can use this overview to inform decisions about which interventions may be most promising to improve particular outcomes. The intervention taxonomy may also assist people to consider the strategies available in relation to specific purposes, for example, gaining skills or being involved in decision making. Researchers and funders can use this overview to identify where more research is needed and assess its priority. The limitations of the available literature due to the lack of evidence for important outcomes and important populations, such as people with multimorbidity, should also be considered in practice and policy decisions.

Tele-health: lessons and strategies from specialists in poison information

OBJECTIVE

The use of the telephone for providing healthcare is growing. The aim of this exploratory study was to describe tele-health lessons and strategies as discussed by specialists who provide information and recommendations on poison control hotlines.

METHODS

Three focus groups of 25 participants who work as specialists in poison information in poison control centers were conducted. Group discussions were analyzed using qualitative content analysis.

RESULTS

Themes that emerged from the data on strategies for telephone communication include: taking control of the call, developing a therapeutic relationship, tailoring communication to fit each caller, preventing information overload, confirming caller understanding, and hands-on training for the development of telephone communication skills.

CONCLUSION

Specialists in poison information identified challenges specific to communicating with patients over the telephone and reported several types of strategies they used to manage them.

PRACTICE IMPLICATIONS

Telephone communication training may be needed to assist health care providers in improving their communication skills.

Analysis of pharmacist-patient communication using the Calgary-Cambridge guide

OBJECTIVE

This study explored communication between pharmacists and patients through application of the Calgary-Cambridge guide [1] to appointment-based pharmacist-patient consultations and considers use of the guide in pharmacy education.

METHODS

Eighteen patients attending appointment-based consultations with five pharmacists were recruited to this qualitative study. Consultations were audio-recorded and observed. Transcripts were coded according to the use of skills within the guide and analysed thematically.

RESULTS

The results showed good use of many skills by pharmacists, particularly signposting and closing the session. Some skills were poorly represented such as listening effectively, eliciting the patient's perspective, effective use of computers and creating patient-centred consultations. A key theme of social conversation was present in the data but this skill was not defined in the guide.

CONCLUSIONS

The Calgary-Cambridge guide was developed for use in medical consultations but its application to pharmacist-patient consultations showed that the guide could be successfully used in pharmacy with some minor alterations.

PRACTICE IMPLICATIONS

Pharmacists may need more training to improve the use of specific communication skills including how to conduct a patient-centred consultation. The Calgary-Cambridge guide is well aligned with many aspects of pharmacist-patient consultations and could help pharmacists to improve their consultation skills.

Consumer-oriented interventions for evidence-based prescribing and medicines use: an overview of systematic reviews

BACKGROUND

Numerous systematic reviews exist on interventions to improve consumers' medicines use, but this research is distributed across diseases, populations and settings. The scope and focus of reviews on consumers' medicines use also varies widely. Such differences create challenges for decision makers seeking review-level evidence to inform decisions about medicines use.

OBJECTIVES

To synthesise the evidence from systematic reviews on the effects of interventions which target healthcare consumers to promote evidence-based prescribing for, and medicines use, by consumers. We sought evidence on the effects on health and other outcomes for healthcare consumers, professionals and services.

METHODS

We included systematic reviews published on the Cochrane Database of Systematic Reviews and the Database of Abstracts of Reviews of Effects. We identified relevant reviews by handsearching both databases from start date to Issue 3 2008. We screened and ranked reviews based on relevance to consumers' medicines use, using criteria developed for this overview. Standardised forms were used to extract data, and reviews were assessed for methodological quality using the AMSTAR instrument. We used standardised language to summarise results within and across reviews; and a further synthesis step was used to give bottom-line statements about intervention effectiveness. Two review authors selected reviews, extracted and analysed data. We used a taxonomy of interventions to categorise reviews.

MAIN RESULTS

We included 37 reviews (18 Cochrane, 19 non-Cochrane), of varied methodological quality.Reviews assessed interventions with diverse aims including support for behaviour change, risk minimisation, skills acquisition and information provision. No reviews aimed to promote systems-level consumer participation in medicines-related activities. Medicines adherence was the most commonly reported outcome, but others such as clinical (health and wellbeing), service use and knowledge outcomes were also reported. Reviews rarely reported adverse events or harms, and the evidence was sparse for several populations, including children and young people, carers, and people with multimorbidity.Promising interventions to improve adherence and other key medicines use outcomes (eg adverse events, knowledge) included self-monitoring and self-management, simplified dosing and interventions directly involving pharmacists. Other strategies showed promise in relation to adherence but their effects were less consistent. These included reminders; education combined with self-management skills training, counselling or support; financial incentives; and lay health worker interventions.No interventions were effective to improve all medicines use outcomes across all diseases, populations or settings. For some interventions, such as information or education provided alone, the evidence suggests ineffectiveness; for many others there is insufficient evidence to determine effects on medicines use outcomes.

AUTHORS' CONCLUSIONS

Systematically assembling the evidence across reviews allows identification of effective or promising interventions to improve consumers' medicines use, as well as those for which the evidence indicates ineffectiveness or uncertainty.Decision makers faced with implementing interventions to improve consumers' medicines use can use this overview to inform these decisions and also to consider the range of interventions available; while researchers and funders can use this overview to determine where research is needed. However, the limitations of the literature relating to the lack of evidence for important outcomes and specific populations, such as people with multimorbidity, should also be considered.

Diabetes and cardiovascular disease interventions by community pharmacists: a systematic review

OBJECTIVE

To systematically review and assess the quality of studies evaluating community pharmacist interventions for preventing or managing diabetes or cardiovascular disease (CVD) and/or their major risk factors.

DATA SOURCES

A comprehensive literature search was performed using MEDLINE (1950-February 2011), EMBASE (1980-February 2011), International Pharmaceutical Abstracts (1970-February 2011), Cumulative Index to Nursing and Allied Health Literature (1982-June 2007), and Cochrane Central Register of Controlled Trials (1898-February 2011). Search terms included: community pharmacy(ies), community pharmacist(s), cardiovascular, diabetes, and intervention. The grey literature was searched using the ProQuest Dissertations and Theses, Theses Canada, and OAlster databases.

STUDY SELECTION AND DATA EXTRACTION

Articles published in English or French with all study designs were considered for the review. Studies were included if they contained interventions designed to reduce the incidence, risk, or mortality of CVD or diabetes; affect clinical indicators of CVD or diabetes mellitus (including hypertension, dyslipidemia, or hemoglobin A(1c)); and/or improve adherence to treatment strategies. Only studies involving interventions carried out primarily by pharmacists in community pharmacy settings were included. Study quality was assessed using a checklist validated for both randomized and nonrandomized studies.

DATA SYNTHESIS

A total of 4142 studies were initially identified, with 40 meeting our inclusion criteria. Eleven studies were randomized controlled trials, 4 were cluster randomized trials, and 2 studies had randomized before-after designs. The remaining studies were controlled before-after (n = 2), cohort (n = 4), and uncontrolled before-after (n = 17) designs. Interventions focused on diabetes (n = 12), hypertension (n = 9), medication adherence (n = 9), lipids (n = 5), evidence-based medication initiation or optimization (n = 3), risk factor prediction scores (n = 1), and body mass index (n = 1). All studies contained interventions focused at the patient level and the majority of studies (34/40) involved interventions directed at both the physician and patient. No specific intervention emerged as superior, and study quality was generally poor, making it difficult to determine the true effect of the interventions.

CONCLUSIONS

Poor study quality, time-intensive interventions, and unproven clinical significance warrant the need for further high-quality studies of community pharmacist interventions for preventing or managing diabetes or CVD and/or their major risk factors.

US pharmacists' effect as team members on patient care: systematic review and meta-analyses

BACKGROUND

One approach postulated to improve the provision of health care is effective utilization of team-based care including pharmacists.

OBJECTIVE

The objective of this study was to conduct a comprehensive systematic review with focused meta-analyses to examine the effects of pharmacist-provided direct patient care on therapeutic, safety, and humanistic outcomes.

METHODS

The following databases were searched from inception to January 2009: NLM PubMed; Ovid/MEDLINE; ABI/INFORM; Health Business Fulltext Elite; Academic Search Complete; International Pharmaceutical Abstracts; PsycINFO; Cochrane Database of Systematic Reviews; National Guideline Clearinghouse; Database of Abstracts of Reviews of Effects; ClinicalTrials.gov; LexisNexis Academic Universe; and Google Scholar. Studies selected included those reporting pharmacist-provided care, comparison groups, and patient-related outcomes. Of these, 56,573 citations were considered. Data were extracted by multidisciplinary study review teams. Variables examined included study characteristics, pharmacists' interventions/services, patient characteristics, and study outcomes. Data for meta-analyses were extracted from randomized controlled trials meeting meta-analysis criteria.

RESULTS

A total of 298 studies were included. Favorable results were found in therapeutic and safety outcomes, and meta-analyses conducted for hemoglobin A1c, LDL cholesterol, blood pressure, and adverse drug events were significant (P < 0.05), favoring pharmacists' direct patient care over comparative services. Results for humanistic outcomes were favorable with variability. Medication adherence, patient knowledge, and quality of life-general health meta-analyses were significant (P < 0.05), favoring pharmacists' direct patient care.

CONCLUSIONS

Pharmacist-provided direct patient care has favorable effects across various patient outcomes, health care settings, and disease states. Incorporating pharmacists as health care team members in direct patient care is a viable solution to help improve US health care.

[Systematic review of the implementation and evaluation of Pharmaceutical Care in hospitalised patients(Pharmaceutical Care implementation in hospitalised patients. Systematic review)]

INTRODUCTION

The persistent morbidity and mortality related to pharmaceutical treatment for hospitalised patients mean that it is necessary to identify scientific criteria for implementing and evaluating Pharmaceutical Care (phC) on the hospital setting.

OBJECTIVE

The purpose of the study is to perform a systematic literature review in order to locate, select and analyse studies on implementing and evaluating phC in hospitalised patients.

MATERIAL AND METHODS

We searched for articles having to do with clinical pharmacy (CP) and phC published between 1990 and 2006, using a restricted search technique combining all descriptors. The databases we searched were Medline, Embase-Drug & Pharmacology and Cochrane Library. We selected original articles and reviews in English or Spanish describing a phC and clinical pharmacy programme having a participating pharmacist and used in hospitalised patients.

RESULTS

We located 66 publications, of which 49 (74.2%) were included and 17 (25.8%) were excluded. We selected 15 (22.7%) on integrating CP and phC in the hospital environment, 18 (27.3%) on implementing phC and 16 (24.2%) relating to evaluating phC programmes.

CONCLUSIONS

In the listed studies, pharmacists have managed to incorporate phC programmes in pharmacy divisions' treatment activities. Joining efforts in order to unify CP and phC criteria should be a plan for a common future in this profession. Patients under care should obtain concrete health benefits from phC use, and hospitals should recognise that they create beneficial effects at a reasonable cost.

Pharmaceutical care services: a systematic review of published studies, 1990 to 2003, examining effectiveness in improving patient outcomes

Objective

To systematically review the evidence for the effect of pharmaceutical care practice on patient outcomes.

Setting

Community and outpatient setting.

Method

Randomised controlled trials (RCTs) published in English between 1990 and 2003 were identified through a systematic literature search. To be included, studies had to assess the effect of a pharmaceutical care intervention, defined as a one-to-one consultation between each patient and a pharmacist with a focus on managing health or resolving drug-related problems, development of a care plan and follow-up.

Key findings

Twenty-two RCTs met the review criteria. Studies targeted general patient populations at risk of drug-related problems, disease-specific target groups or patients with risk factors including hypertension and raised cholesterol. While a number of trials have been undertaken, the variability in the application of endpoints utilised means the evidence for effectiveness of single endpoints apart from quality of life is generally limited to one or two controlled trial results. Collectively, the studies provide evidence that the service improves signs and symptoms for people with asthma, surrogate endpoints such as blood pressure, cholesterol levels and glycosylated haemoglobin and medication use, but do not provide evidence supporting improved health-related quality of life. One study showed an improvement in combined all-cause mortality and non-fatal heart failure-related events in patients with heart failure.

Conclusion

Pharmaceutical care services are effective in improving medication use and surrogate endpoints, but improvement in other outcomes is less conclusive. Given that the focus of the service is to resolve medication-related problems, consideration should be given to the use of adverse drug events and resolution of medication-related problems as an outcome measure in future studies.

Pharmacists' Perspectives on Providing Chronic Disease Management Services in the Community — Part I: Current Practice Environment

Background:

Several practice models have been developed to support pharmacists in providing chronic disease management. However, most of these models have not been readily accepted by pharmacists, which has led to low uptake and short-term change.

Methods:

Pharmacists were recruited to participate in focus groups held in Alberta and British Columbia. Qualitative methodologies involving a phenomenological approach with content analysis were used to gather and analyze information.

Results:

In total, 36 pharmacists participated in 8 focus groups. Analysis of their discussions revealed 4 main themes: the current practice environment and the need for education about, remuneration for and a plan for the implementation of chronic disease management services. Participants cited several challenges to the provision of this type of care, as experienced in the current practice environment: time constraints; relationships with physicians, patients and employers; limited access to clinical information; and absence of a model for chronic disease management in pharmacy practice. However, these perceptions were not universal, and pharmacists with experience in this area described some of these commonly cited “challenges” (e.g., relationships with physicians) as enablers in their own practices. In addition, staff pharmacists, regional managers and owners often had differing opinions about the key challenges and the role of remuneration.

Conclusion:

Some of the perceived challenges to providing chronic disease management described by staff pharmacists were not consistently supported by employers or those with experience in this practice area. This observation suggests that the greatest challenge to developing a successful model of chronic disease management for pharmacists lies in pharmacists' own perceptions about their relationships with other health care providers and their own role as health care professionals. These issues must be addressed if the practice of pharmacy is to move forward.

Collaboration between pharmacists, physicians and nurse practitioners: a qualitative investigation of working relationships in the inpatient medical setting

While collaborative, team-based care has the potential to improve medication use and reduce adverse drug events and cost, less attention is paid to understanding the processes of well functioning teams. This paper presents the findings from key informant interviews and reflective journaling from pharmacists, physicians and nurse practitioners participating in a multicentre, controlled clinical trial of team-based pharmacist care in hospitalized medical patients. A phenomenological approach guided the data analysis and content analysis was the primary tool for unitizing, categorizing and identifying emerging themes. Pharmacists experienced highs (developing trusting relationships and making positive contributions to patient care) and lows (struggling with documentation and workload) during integration into the medical care team. From the perspective of the participating pharmacists, nurse practitioners and physicians, the integration of pharmacists into the teams was felt to have facilitated positive patient outcomes by improving team drug-therapy decision-making, continuity of care and patient safety. Additionally, the study increased the awareness of all team members' potential roles so that pharmacists, nurses and physicians could play a part in and benefit from working together as a team. Focussed attention on how practice is structured, team process and ongoing support would enable successful implementation of team-based care in a larger context. (ClinicalTrials.gov number, NCT00351676).

Capturing outcomes of clinical activities performed by a rounding pharmacist practicing in a team environment: the COLLABORATE study [NCT00351676]

BACKGROUND

Medical inpatients are at risk for suboptimal health outcomes from adverse drug events and under-use of evidence-based therapies. We sought to determine whether collaborative care including a team-based clinical pharmacist improves the quality of prescribed drug therapy and reduces hospital readmission.

METHODS

Multicenter, quasi-randomized, controlled clinical trial. Consecutive patients admitted to 2 internal and 2 family medicine teams in 3 teaching hospitals between January 30, 2006 and February 2, 2007 were included. Team care patients received proactive clinical pharmacist services (medication history, patient-care round participation, resolution of drug-related issues, and discharge counseling). Usual care patients received traditional reactive clinical pharmacist services. The primary outcome was the overall quality score measured retrospectively by a blinded chart reviewer using 20 indicators targeting 5 conditions. Secondary outcomes included 3- and 6-month readmission.

RESULTS

A total of 452 patients (220 team care, 231 usual care, mean age: 74 years, 46% male) met eligibility criteria. Team care patients were more likely than usual care patients to receive care specified by the indicators overall (56.4% vs. 45.3%; adjusted mean difference: 10.4%; 95% confidence interval [CI]: 4.9%, 15.7%) and for each targeted disease state except for heart failure. Team care patients experienced fewer readmissions at 3 months (36.2% vs. 45.5%; adjusted OR: 0.63; 95% CI: 0.42, 0.94) but not at 6 months (50.7% vs. 56.3%; adjusted OR; 0.78; 95% CI: 0.53, 1.15).

CONCLUSIONS

In patients admitted to internal and family medicine teams, team-based care including a clinical pharmacist, improved the overall quality of medication use and reduced rates of readmission.

Study of Understanding Pharmacists' Perspectives on Remuneration and Transition toward Chronic Disease Management (SUPPORT-CDM): Results of an Alberta-Wide Survey of Community Pharmacists

Background:

Strong evidence supports the benefits of pharmacist intervention and chronic disease management (CDM) for patients, yet most pharmacists are not providing such services. The purpose of this study was to better understand pharmacists' perceptions of CDM and potential remuneration models.

Methods:

We developed and tested a web-based survey based on the issues identified in a series of focus groups involving pharmacists: current practice setting, education, remuneration models, current practice environment and implementation. An invitation to complete the survey was e-mailed to registered pharmacists and was included in a weekly newsletter to Alberta pharmacists in January 2008, with 3 subsequent reminders to complete the survey.

Results:

Responses from 140 pharmacists were included. Pharmacists were most interested in providing CDM for diabetes (79%), although only 49% were presently comfortable with managing diabetes. The top enablers for provision of CDM included pharmacists' desire to change their scope of practice, a supportive work environment and patient demand. The top barriers included a lack of time to engage in CDM, lack of remuneration and staffing issues. Interestingly, relatively few identified pharmacists' resistance to change and difficulty finding eligible patients (38% and 25%, respectively) as important barriers. The majority of pharmacists agreed that payment should be shared between the pharmacy and the pharmacist as a fee-for-service. The average amount pharmacists expected for this model was $44.23/service.

Conclusions:

Pharmacists showed interest but may lack the confidence to provide CDM services to patients. Many of the facilitators and barriers point toward the need for a sustainable remuneration model for pharmacists' clinical care. We plan to use these results to help develop such a model.

Clinical and economic outcomes of pharmaceutical services related to antibiotic use: a literature review

AIM OF THE REVIEW

To identify and review the clinical and economic impact of pharmacists' interventions on antibiotic use.

METHOD

A literature search was conducted on Medline (1966-2003) to identify original articles measuring the impact of pharmacists' interventions on antimicrobial therapy at patient's or prescriber's level.

RESULTS

Forty-three articles were included: 20 uncontrolled before-after studies, four controlled before-after studies, five controlled trials, 12 randomized controlled trials and two interrupted time series (ITS). The described interventions were grouped into four categories: patient-specific recommendations (pharmacists' interventions concerning patient-specific drug therapy), implementation of policies, education, and therapeutic drug monitoring. These interventions were often combined to provide a multifaceted intervention, making it difficult to isolate the impact of one specific intervention. Measured outcomes were: appropriateness of prescribing (evaluated in 17 studies, 16 showing significant improvement), costs (analysed in 22 studies, nine showing a statistically significant reduction in costs after or with the intervention), and length of hospital stay (mixed results). Other measured outcomes were: drug use, prescriptions, length of treatment, dose intervals, switch to oral route, mortality rate, and treatment failure.

CONCLUSION

Over the years, the number of studies and quality of methodology has increased. The most frequently observed outcomes with a positive impact were appropriateness of prescribing and cost savings. The vast majority of studies used multiple interventions, in conjunction with pharmacists' recommendations to physicians. Coupled with the use of practice guidelines or educational strategies, these interventions demonstrated a positive impact on economic or clinical outcomes. However, the data are still sparse and sometimes contradictory; therefore, further studies with randomized controlled designs are needed.

The effects of introducing a clinical pharmacist on orthopaedic wards in Denmark

OBJECTIVE

To assess the effects and cost effects of introducing clinical pharmacists on hospital wards.

METHODS

Comparative prospective study on four orthopaedic surgical wards in two hospitals. The primary effect variables were 10 target areas widely considered to be indicators of good prescription practice. Prescriptions not following good practice in these intervention areas were defined as "sub-optimal prescriptions," and then discussed between a physician and a clinical pharmacist. The primary parameter was the difference in the number of days with a sub-optimal prescription (Mann-Whitney test).

RESULTS

On an average 20% of all the patients had a sub-optimal prescription. Of these, 70% were changed by the physician after intervention by the clinical pharmacist. There was a statistically significant difference in the duration of days in treatment with a sub-optimal prescription. Where sub-optimal prescriptions were changed, 43% resulted in cost reductions. The reductions achieved could cover 47% of the costs of clinical pharmacy service.

CONCLUSION

Clinical pharmacy services offered to four orthopaedic surgical wards resulted in reduction of sub-optimal prescriptions. Every time the pharmacist screened seven patients one sub-optimal prescription was found and adjusted. The reduction in medicine costs due to adjusted sub-optimal prescriptions could not cover the whole cost of clinical pharmacy service.

Strategies for Evaluating Clinical Pharmacy Services

These series of articles of the Director's Forum switch their focus from the core competencies of hospital pharmacy practice to programs that enhance the ability of the pharmacy to provide patient-centered services. In the September 2006 issue, decentralized pharmacy services were reviewed and recommended as an effective patient-centered strategy for a hospital pharmacy. In the October 2006 issue, strategies for developing advanced practice clinical programs were discussed. These services place the pharmacist closer to patients, enhancing their ability to be involved directly in all aspects of effective medication therapy management.

Tricks for improving compliance with acne therapy

Adherence to a medical regimen is the most important aspect of therapeutic efficacy. It goes without saying that a drug that is not used will not be effective. Reasons for noncompliance can be related to the specific disease state, to characteristics of the drugs chosen, to patient personality traits, and to effectiveness of the clinician in dealing with the individual patient. Recognizing, confronting, and improving noncompliant behavior are all part of an effective doctor-patient relationship.

Impacto clínico y económico de la incorporación del farmacéutico residente en el equipo asistencial

OBJECTIVE

To quantify the impact of the incorporation of a hospital pharmacy resident into a healthcare team. To describe the work schedule followed.

METHOD

The resident was integrated for 8 months in Medical Oncology, Intensive Care Unit, and Oncology Day Hospital. Interventions were recorded and evaluated using Atefarm software. Problem characteristics, type, and severity were recorded, as were acceptance, and costs avoided by interventions.

RESULTS

In all, 2,415 drug-related problems were detected (10 per day, and 3.6 per patient), and 2,545 interventions for 672 patients were carried out. Most common problems were inadequate treatment duration, and conversion to oral route. Sixty-one percent of errors were prevented. Sixty-five percent of interventions influenced safety, 35% efficiency, and 25% effectiveness. Ninety-four percent of interventions were accepted. Costs avoided by the pharmacist amounted to 3,133 euro per month.

CONCLUSIONS

The integration of a pharmacist in the healthcare teams optimizes therapy, reduces costs, prevents adverse events, and offers healthcare education.

When does pharmaceutical care impact health outcomes? A comparison of community pharmacy-based studies of pharmaceutical care for patients with asthma

BACKGROUND

Pharmaceutical care (PC) as a philosophy of care and practice model is now >14 years old. It is important to determine whether PC influences health outcomes. Such outcomes are best studied in specific disease states where variables are minimized and specific outcomes have been established. We analyzed 4 multi-site controlled studies that evaluated PC in community pharmacies for patients with asthma. Study results varied widely.

OBJECTIVE

To understand factors contributing to positive outcomes from PC for asthma.

METHODS

The 4 studies were compared on the basis of 10 aspects of their research design, as well as 10 elements of PC. Dr. McLean conducted the initial analysis, and his assessments were confirmed by Dr. MacKeigan.

RESULTS

Important differences were found in the type of pharmacy where PC was delivered (chain vs independent), how pharmacies were selected (required vs volunteered), patient selection (on asthma medication vs uncontrolled disease), pharmacist training (4-h workshop vs certification over several weeks), the nature of PC protocol (computer reminders vs detailed care protocol), rigor of the protocol (intervention vs requirement to reach self-management), and the level of pharmacist adherence to the PC protocol (<50% vs 90%). Differences were also found in study design.

CONCLUSIONS

More favorable PC outcomes were associated with use of all elements of PC, independent pharmacies, pharmacist certification, a detailed PC protocol, targeting patients with uncontrolled asthma, and a practice system facilitating PC.

Effectiveness of Interventions by Community Pharmacists to Improve Patient Adherence to Chronic Medication: A Systematic Review

OBJECTIVE:

To systematically review the impact of interventions by community pharmacists on patients' adherence with chronic medication.

DATA SOURCES:

A MEDLINE search (1966–November 30, 2003) and a review of reference sections were done to identify all pertinent English- and German-language journal articles. Search terms included compliance, adherence, persistence, discontinuation, pharmacist, and intervention.

STUDY SELECTION AND DATA EXTRACTION:

From each relevant study, the following data were extracted: study design, country, disease, number of patients, patients' age and gender, type of intervention, duration of follow-up, method of measurement of adherence and adherence rate, and data concerning the quality of the included studies.

DATA SYNTHESIS:

A total of 162 studies were identified, of which 18 matched our inclusion criteria. Twelve were randomized controlled trials and 6 were non-crossover single-group trials. Eight studies showed significant improvement of adherence at one or more time points. Eight studies did not show any effect, 7 of which were randomized controlled trials. In most studies, adherence rates at baseline were high compared with rates reported in the general population. Counseling, monitoring, and education during weekly or monthly appointments showed some effect. However, these same types of interventions showed no effect in other studies. The overall quality of the included studies was low.

CONCLUSIONS:

Currently, it is impossible to identify an overall successful adherence-improving strategy performed by pharmacists. More well-designed and well-conducted studies on the effectiveness of interventions by a community pharmacist to improve patient adherence to chronic medication need to be performed.

Implementation of a Patient Medication Assistance Program in a Community Pharmacy Setting

OBJECTIVE

To describe the establishment of a community pharmacy-based patient medication assistance program to improve access to medications by indigent patients, lessen the burden placed on physicians in obtaining such medications, reduce the amount of money spent on such medications by area charitable organizations, and improve therapeutic outcomes by improving patient adherence with therapy.

SETTING

Supermarket-based pharmacy in Ashland, Ohio.

PRACTICE DESCRIPTION

Community pharmacy.

PRACTICE INNOVATION

A partnership was developed among Buehler's Pharmacy #3, United Way of Ashland County, and United Way Affiliates to establish a community pharmacy-based medication assistance program to help indigent patients obtain needed medications through manufacturer assistance programs and discount card programs.

INTERVENTIONS

Following initial screening by a United Way affiliate agency, patients are seen by appointment by a Certified Pharmacy Technician at the pharmacy. An electronic application is completed, printed, and sent to the patient's physician for signatures and medication orders. The paperwork is returned to the pharmacy, where it is completed, signed by the patient, and filed. The patient pays the United Way agency $10 and the pharmacy $15 for these services.

MAIN OUTCOME MEASURES

Number of prescriptions dispensed cumulatively from April 1, 2003, to July 31, 2003, within the program, patients' cumulative savings, and community response.

RESULTS

Between April 1, 2003, and July 31, 2003, a total of 123 patients and 47 physicians were served, and 512 medications valued at $112,139.00 were applied for and/or procured. The time lapse between filing of paperwork and receipt of medications varies from 1 to 6 weeks. While some manufacturers ship product to physicians or directly to patients, the process works better when the product is sent to the pharmacy, where it can be added to the patient's profile, screened for drug interactions and allergies, and dispensed with proper labels and counseling.

CONCLUSION

Establishing a community pharmacy-based medication assistance program is an innovative spin on the traditional physician office, advocacy, or health-system setting and was found to be beneficial to the patients, physicians and other health care providers, and the community it served.

Advancing pharmacy practice through research: a 2004 perspective

OBJECTIVE

To share the current reflections, perspectives, and recommendations of the Pharmacy Practice Research Roundtable about a research agenda for pharmacy practice in the United States.

DATA SOURCES

Peer-reviewed medical literature, national and international developments relating to health care, laws and regulations affecting pharmacy practice, information provided by invited guests, and personal experiences of roundtable members.

SUMMARY

Current realities with the potential to affect pharmacy practice relate to strategies for pursuing pharmacy practice research. Emerging roles and activities of pharmacists in health systems and the community are identified in this article. Based on consideration of the realities, strategies, and new roles, priority areas for pharmacy practice research are identified. Recommendations for research emphasis include the following: (1) define medication therapy management services that relate to medication safety, improved management of chronic disease, and implementation of a Medicare ambulatory drug benefit; (2) evaluate pharmacy practice models from external and internal perspectives; (3) differentiate patient groups based on their need for, access to, and affinity for pharmacist services; (4) define achievable roles and responsibilities for patients in medication use; (5) provide a deeper understanding about the professional workforce in pharmacy; (6) examine the gap between academic practice models and actual practice and test strategies to reduce the gap; and (7) evaluate the applicability to the United States of evolving pharmacy practice activities in other countries.

CONCLUSION

A national pharmacy practice research agenda should be pursued in the context of those issues that are influencing health care.

Impact of Pharmacists' Interventions on the Pediatric Discharge Medication Process

BACKGROUND

To our knowledge, as of August 19, 2004, the impact of pharmacists' interventions on pediatric patients and their caregivers' ability to obtain discharge medications from community pharmacies in a timely fashion has not been described.

OBJECTIVE

To evaluate the impact of pharmacists' interventions on patients' likelihood of obtaining medications within 24 hours of hospital discharge.

METHODS

Patients meeting study criteria were randomized to an intervention or control group. The intervention was a proactive program of discharge planning by the pharmacy team. All study patients received a follow-up telephone interview to assess the amount of time needed to obtain medications and caregivers' knowledge of how to administer medications. A multivariate linear regression was conducted to assess the association between variables such as insurance, place of residence, number of prescribed medications, and the probability to obtain medications within 24 hours of hospital discharge.

RESULTS

The final analysis included 81 control patients and 91 intervention patients. After controlling for a number of factors, the intervention group was able to have obtained medications within 24 hours more often than the control group (84% vs 69%; p = 0.027). Caregivers' knowledge of how to correctly administer medications did not differ between the 2 groups.

CONCLUSIONS

Our results suggest that the coordinated efforts of pharmacists' interventions during the discharge process may have a positive impact. Our observations may be used to establish criteria for identifying patients at risk for problems with obtaining medications at discharge.

Changing relationships: attitudes and opinions of general practitioners and pharmacists regarding the role of the community pharmacist

BACKGROUND

Relationship between general practitioners and pharmacists.

AIM

To explore similarities and differences in opinions between general practitioners and pharmacists about the pharmacist's role. To identify factors which determine the attitude of the general practitioner towards the role of the pharmacist as a care provider.

DESIGN

Cross-sectional questionnaire survey.

SETTING

The Netherlands, 2001.

PARTICIPANTS

926 non-dispensing general practitioners, 93 dispensing general practitioners and 328 community pharmacists.

METHODS

Statements about the pharmacist's position in primary care were formulated. The attitude towards the pharmacist's care-providing function was determined by adding the scores to the statements. Data were collected on age, gender, professional experience, trainership, type and size of practice, electronic communication, urbanisation level, part-time work, work pressure, postgraduate training, pharmacotherapy audit meetings (PTAMs), the mutual relationship and the desired role of the pharmacist in pharmacotherapy.

RESULTS

No significant differences in opinions were found between pharmacists and non-dispending general practitioners with respect to a number of the pharmacist's signalling tasks. Eighty-six percent (CI 83-89) of non-dispensing general practitioners and eighty-two percent (CI 76-87) of pharmacists shared the opinion that pharmacists need to provide the general practitioner with feedback on prescription figures. Furthermore, 85% (CI 82-88) of the non-dispensing general practitioners and 80% (CI 75-86) of the pharmacists believed that pharmacists should suggest items for the PTAM agenda, based on prescription patterns they notice in their pharmacy. The attitude of general practitioners towards the care-providing function of the community pharmacist correlates significantly with the relationship between general practitioners and pharmacists (P < 0.001). There is also a significant difference (P < 0.001) in the attitude score between dispensing and non-dispensing general practitioners: dispensing general practitioners scored lower on the attitude scale.

CONCLUSION

Pharmacists and general practitioners largely agree on the pharmacotherapeutic signalling role that a pharmacist should fulfill. A good relationship benefits the attitude of general practitioners towards the pharmacist's care-providing function.

A Primer for Developing Pharmacist-Managed Clinics in the Outpatient Setting

Pharmacist-managed clinics exist in many practice settings, such as physician offices, hospital-based outpatient clinics, and pharmacies. This article is intended to serve as a primer for pharmacists who wish to establish clinical pharmacy services in these settings. Recommendations for beginning this process are delineated. Information on building initial support, developing a needs assessment analysis, selecting the focus of new clinical services, developing a detailed clinic proposal, and marketing new services is provided. In a comprehensive review of how to develop a clinic proposal, the purpose, background information, proposed clinic structure, implications, assessment, billing issues, financial summary, and resources requested are discussed. Opportunities for financial compensation in various practice settings, such as the physician outpatient clinic, hospital-based outpatient clinic, and community pharmacy, are also reviewed.

Evidence of the economic benefit of clinical pharmacy services: 1996-2000

We sought to summarize and assess original evaluations of the economic impact of clinical pharmacy services published from 1996-2000, and to provide recommendations and methodologic considerations for future research. A systematic literature search was conducted to identify articles that were then blinded and randomly assigned to reviewers who confirmed inclusion and abstracted key information. Results were compared with those of a similar review of literature published from 1988-1995. In the 59 included articles, the studies were conducted across a variety of practice sites that consisted of hospitals (52%), community pharmacies and clinics (41%), health maintenance organizations (3%), and long-term or intermediate care facilities (3%). They focused on a broad range of clinical pharmacy services such as general pharmacotherapeutic monitoring (47%), target drug programs (20%), disease management programs (10%), and patient education or cognitive services (10%). Compared with the studies of the previous review, a greater proportion of evaluations were conducted in community pharmacies or clinics, and the types of services evaluated tended to be more comprehensive rather than specialized. Articles were categorized by type of evaluation: 36% were considered outcome analyses, 24% full economic analyses, 17% outcome descriptions, 15% cost and outcome descriptions, and 8% cost analyses. Compared with the studies of the previous review, a greater proportion of studies in the current review used more rigorous study designs. Most studies reported positive financial benefits of the clinical pharmacy service evaluated. In 16 studies, a benefit:cost ratio was reported by the authors or was able to be calculated by the reviewers (these ranged from 1.7:1-17.0:1, median 4.68:1). The body of literature from this 5-year period provides continued evidence of the economic benefit of clinical pharmacy services. Although the quality of study design has improved, whenever possible, future evaluations of this type should incorporate methodologies that will further enhance the strength of evidence of this literature and the conclusions that may be drawn from it.