Transplant Pharmacy: 30 Years of Improving Patient Care

Clinical evaluation of pharmacists' interventions on multidisciplinary lung transplant outpatients' management: results of a 7-year observational study

OBJECTIVES

Lung transplant (LT) recipients require multidisciplinary care because of the complexity of therapeutic management. Pharmacists are able to detect drug-related problems and provide recommendations to physicians through pharmacists' interventions (PIs). We aimed at assessing the clinical impact of PIs on therapeutic management in LT outpatients.

DESIGN

Data were collected prospectively from an LT recipients cohort during 7 years. A multidisciplinary committee assessed retrospectively the clinical impact of accepted PIs.

SETTING

French University Hospital.

PARTICIPANTS

LT outpatients followed from 2009 to 2015.

PRIMARY OUTCOME MEASURES

Clinical impact of PIs performed by pharmacists using the CLEO tool and the Pareto chart.

RESULTS

1449 PIs led to a change in patient therapeutic management and were mainly related to wrong dosage (39.6%) and untreated indication (19.6%). The clinical impact of PIs was 'avoids fatality', 'major' and 'moderate', in 0.1%, 7.0% and 57.9%, respectively. Immunosuppressants, antimycotics for systemic use and antithrombotic agents had the greatest clinical impact according to the Pareto chart. PIs related to drug-drug interactions (10%) mainly had a moderate and major clinical impact (82.3%, p<0.0001).

CONCLUSION

Clinical pharmacists play a key role for detecting drug-related problems mostly leading to a change in therapeutic management among LT outpatients. Our study provides a new insight to analyse the clinical impact of PIs in order to target PIs which have most value and contribute to patient care through interdisciplinary approach.

Dynamic Interplay of Pharmacy Learners During a Solid Organ Transplantation Learning Experience

Institutions with established clinical pharmacy services have the ability to offer focused patient care learning experiences, often led by a clinical specialist, for pharmacy residents and pharmacy students. Since all parties are continually involved in professional development and lifelong learning, the aforementioned groups can all be considered “pharmacy learners.” By utilizing the dynamic interplay and collaboration between pharmacy learners through direct and nondirect patient care activities, experiential and educational opportunities may be improved and enhanced for each learner. A tiered learning approach engages individuals in areas such as direct patient care, patient education, presentations, research projects, career development, and the feedback process. We describe our experience during a solid organ transplantation learning experience using a layered learning practice model that included a clinical pharmacy specialist, a postgraduate year 2 specialty pharmacy resident, a postgraduate year 1 pharmacy resident, and a pharmacy student.

A National Survey Assessing the Current Workforce of Transplant Pharmacists Across Accredited U.S. Solid Organ Transplant Programs

Integration of pharmacists into multidisciplinary transplant patient care has advanced in recent years, with limited data available to evaluate the current status of the profession. This was a national survey developed as an AST Pharmacy COP initiative. Responses were solicited from pharmacists practicing at U.S. transplant programs based on UNOS listing; 176 participants from 113 centers (41%) responded, with 79% practicing ≤10 years. There is a median of 1.4 pharmacist full-time equivalents (FTEs) (range 0.1-7.1) for every 100 transplants. The predominant activities performed by pharmacists during the transplant phase include medication review (95%), lab review (92%), allergy review (88%), medication therapy management (92%), bedside rounds (87%), medication education (79%), documentation (71%), and coordinating discharge medications (58%). Similar activities were reported during the other phases, but participation was less common. The involvement of dedicated transplant pharmacists within multidisciplinary care has become standard at a large number of centers, although expansion is still needed to ensure core pharmaceutical care components are provided to all transplant recipients across all centers. These results inform on the typical responsibilities of pharmacists practicing within the field of transplantation and illustrate that the level of pharmacist involvement significantly varies across transplant centers and the phases of transplantation.

Value of solid organ transplant-trained pharmacists in transplant infectious diseases

Advances in organ transplantation have led to improved graft and patient survival. Transplant pharmacist's education and training uniquely position them to contribute knowledge and skills to the management of these highly complex patients. In 2004, the United Network for Organ Sharing bylaws added requirements that all transplant programs identify one or more pharmacists with experience in transplant pharmacotherapy to be responsible for providing pharmaceutical care to solid organ transplant recipients. These bylaws also delineated the transplant pharmacist's roles and responsibilities. To further support these efforts, in 2007 the Centers for Medicare and Medicaid Services accreditation standards for transplant centers also mandated that a center have a designated, qualified expert in transplant pharmacology as a multidisciplinary team member. The transplant pharmacist is a consistent member of the transplant team that can add value to the multidisciplinary approach of prevention and treatment of transplant infectious diseases through all phases of transplant care.

Pilot study of a pharmaceutical care intervention in an outpatient lung transplant clinic

BACKGROUND

Lung transplant recipients have complex drug regimens. Study objectives were to assess drug therapy problems (DTPs), pharmacist recommendations, and patient satisfaction with pharmacist services.

METHODS

Using a pharmaceutical care assessment process, pharmacists identified DTPs and made therapeutic recommendations. Number of DTPs identified per pharmacist visit was calculated and compared to standard care visits through retrospective chart review. Potential clinical impact of recommendations was evaluated by blinded clinicians. Patient satisfaction was assessed via survey.

RESULTS

Fifty-five DTPs were identified in 43 patients over 50 pharmacist visits (1.05 ± 1.34 DTPs per visit). In these same patients, rate of DTP identification was 0.51 ± 0.64 DTPs per standard visit in the preceding two-wk period (p = 0.018 vs. pharmacist visit). The most common DTPs identified by the pharmacist were adverse drug effect (27%) and untreated indication (25%). Overall, 62% of pharmacist recommendations were rated very significant or significant. Survey return rate was 58% and satisfaction scores ranged from 3 to 5 out of 5. Review of medications and teaching regarding the use of medications received the most "very satisfied" and "highly important" scores.

CONCLUSIONS

Pharmacists can make valuable contributions in a lung transplant clinic setting by identifying DTPs and making recommendations with a positive impact on patient outcomes and satisfaction.

Billing for outpatient transplant pharmacy services

PURPOSE

The economic impact of out-patient pharmacy services in a transplant program was evaluated.

METHODS

Full-time kidney transplant pharmacy services were implemented at Providence Sacred Heart Medical Center (PSHMC) in the fall of 2008, with two pharmacists combining hours to provide one full-time-equivalent position. At PSHMC, posttransplantation patients are seen three times per week. The number of patient visits with pharmacists for 2010 was compared with the total number of patient visits. The face-to-face time spent with the patient was translated to a level of billing that was associated with a set reimbursement schedule. For each patient encounter in which a pharmacist was involved, the incremental difference between the nursing and pharmacy levels of billing was examined, as were the levels most often billed by pharmacists. The difference in billing levels between pharmacists and nurses for the same patient encounter was also evaluated.

RESULTS

Overall, pharmacist visits accounted for 208 (22%) of the 994 out-patient kidney transplant visits in 2010, with pharmacists billing at a higher level of acuity compared with nursing for the same patient encounter 48% of the time. This translated to an approximate increase of $100 per patient visit. For the one-year study period, pharmacists utilizing facility- fee billing increased out-patient reimbursement by approximately $10,000.

CONCLUSION

By utilizing outpatient facility-fee billing for pharmacy services, the transplant program at PSHMC increased reimbursement in the outpatient setting.

Evolution of the role of the transplant pharmacist on the multidisciplinary transplant team

Transplant pharmacists have been recognized as an essential part of the transplant team by their colleagues along with several governing and professional organizations. The specific education, training and responsibilities of the transplant pharmacist have not been clearly delineated in the literature. Various pharmacists across the country have been called upon to serve on the transplant team necessitating standardization of their fundamental and desirable activities. Therefore, the purpose of this manuscript is to describe the training and role of a transplant pharmacist on the patient care team and provide a roadmap to implementation of novel transplant pharmacy services.

Pharmacotherapy for Mechanical Circulatory Support: A Comprehensive Review

Objective

To provide a comprehensive review of the pharmacotherapy associated with the provision of mechanical circulatory support (MCS) to patients with end-stage heart failure and guidance regarding the selection, assessment, and optimization of drug therapy for this population.

Data Sources:

The MEDLINE/PubMed, EMBASE, and Cochrane databases were searched from 1960 to July 2010 for articles published in English using the search terms mechanical circulatory support, ventricular assist system, ventricular assist device, left ventricular assist device, right ventricular assist device, biventricular assist device, total artificial heart, pulsatile, positive displacement, axial, centrifugal, hemostasis, bleeding, hemodynamic, blood pressure, thrombosis, antithrombotic therapy, anticoagulant, antiplatelet, right ventricular failure, ventricular arrhythmia, anemia, arteriovenous malformation, stroke, infection, and clinical pharmacist.

Study Selection And Data Extraction:

All relevant original studies, metaanalyses, systematic reviews, guidelines, and reviews were assessed for inclusion. References from pertinent articles were examined for content not found during the initial search.

Data Synthesis:

MCS has advanced significantly since the first left ventricular assist device was implanted in 1966. Further advancements in MCS technology that occurred in the tatter decade are changing the overall management of end-stage heart failure care and cardiac transplantation. These pumps allow for improved bridge-to-transplant rates, enhanced survival, and quality of life. Pharmacotherapy associated with MCS devices may optimize the performance of the pumps and improve patient outcomes, as well as minimize morbidity related to their adverse effects. This review highlights the knowledge needed to provide appropriate clinical pharmacy services for patients supported by MCS devices.

Conclusions:

The HeartMate II clinical investigators called for the involvement of pharmacists in MCS patient assessment and optimization. Pharmacotherapeutic management of patients supported with MCS devices requires individualized care, with pharmacists as part of the team, based on the characteristics of each pump and recipient.

Process of care events in transplantation: effects on the cost of hospitalization

Deviations in the processes of healthcare delivery that affect patient outcomes are recognized to have an impact on the cost of hospitalization. Whether deviations that do not affect patient outcome affects cost has not been studied. We have analyzed process of care (POC) events that were reported in a large transplantation service (n = 3,012) in 2005, delineating whether or not there was a health consequence of the event and assessing the impact on hospital resource utilization. Propensity score matching was used to adjust for patient differences. The rate of POC events varied by transplanted organ: from 10.8 per 1000 patient days (kidney) to 17.3 (liver). The probability of a POC event increased with severity of illness. The majority (81.5%) of the POC events had no apparent effect on patients' health (63.6% no effect and 17.9% unknown). POC events were associated with longer length of stay (LOS) and higher costs independent of whether there was a patient health impact. Multiple events during the same hospitalization were associated with the highest impact on LOS and cost. POC events in transplantation occur frequently, more often in sicker patients and, although the majority of POC events do not harm the patient, their effect on resource utilization is significant.

Clinical pharmacy services and solid organ transplantation: a literature review

AIM OF THE REVIEW

Organ transplantation represents the therapy of choice for most types of end-stage organ failure, and post-transplant patient care warrants great attention. The aim of this study was to summarise the available evidence regarding the role and impact of clinical pharmacy services in the care of solid organ transplant patients.

METHODS

A search of the literature was conducted using the MEDLINE, EMBASE and IPA databases to identify studies relevant to our investigation of the impact of clinical pharmacists' interventions.

RESULTS

Only five out of nineteen of the included studies were randomised controlled trials; eleven studies were descriptive, and three were before-after studies. Interventions performed in these studies consisted of routine clinical pharmacy services with a focus on identifying, resolving and preventing drug-related problems; clinical pharmacy services with a focus on therapeutic drug monitoring; and those with a focus on compliance enhancement and educational interventions. The number and type of interventions and the physicians' acceptance rates were assessed in the majority of the included studies. Acceptance rates were generally above 95%, and most studies reported that clinical pharmacy services had a positive impact on the care of solid organ transplant patients. Positive perceptions of patients and health care professionals are also reported. In two of the studies, patients' compliance rates and drug knowledge were assessed following counselling by a pharmacist. Dosing-related interventions were the most common interventions proposed. Immunosuppressants, cardiovascular drugs and antimicrobials were the drug classes most affected by the clinical pharmacists' interventions.

CONCLUSIONS

High quality evidence that supports the benefit of clinical pharmacy services in the care of solid organ transplant patients is rare. Nevertheless, all of the included studies showed that clinical pharmacy services had a positive impact. Furthermore, all included studies showed that patients and physicians appreciated clinical pharmacists. The various outcome measures used in these studies were improved by interactions with clinical pharmacists. More randomised controlled trials are needed to contribute to the paucity of the existing evidence.