ASHP guidelines: Minimum standard for ambulatory care pharmacy practice

Reconsidering the residency training pathway for ambulatory care pharmacists

Ambulatory care, commonly found in primary care settings, is a growing area of pharmacy practice supported by an expanding number of residency training opportunities in this setting. As this practice expands, the profession has chosen to adopt structures that define it as a specialty practice area, a departure from the medical profession. A key example of this definition is the profession's alignment of residency training for this setting within postgraduate year 2 standards. In this commentary, we explore the implications of this approach and share experience from more than 20 years of statewide ambulatory care residency training in Minnesota. We question whether current training expectations are rooted in an objective evaluation of the knowledge and skills required for ambulatory care pharmacy practice. Ultimately, we call on practice leaders to take account of the impact on current training expectations for learners and pharmacy workforce development and seek a rationalization of the training pathway for ambulatory care practice.

Community pharmacists' skills and practice regarding dispensing fiscalized substances: a cross-sectional survey

Background: The use of drugs containing fiscalized substances is essential in different medical areas, including pain management, obstetric emergencies, and the treatment of mental disorders. However, due to their potential for abuse and negative health effects, the dispensing of these substances demands pharmacists with the requisite skills and practice. Objective: This study assesses the skills and practices of pharmacy personnel in the United Arab Emirates (UAE) regarding the dispensing of tramadol, a medication containing fiscalized substances, in community pharmacies. Methodology: A cross-sectional study was conducted. Community Pharmacies were chosen via random sampling, and seven well-trained final year pharmacy students visited them and conducted face-to-face interviews. The survey tool covered items highlighting the demographic data of the subjects, and items on the practice and skills regarding dispensing the fiscalized substances. The content validity ratio values of all tool questions were more than 0.78, suggesting acceptable validity and the Cronbach's α of 0.75 showed as acceptable internal reliability. The primary outcome measures of interest were the skills and practice regarding dispensing Fiscalized substances. Results: A total of 612 pharmacists were recruited in the study. The average practice score was 80%. There was a statistically significant association (p < 0.05) between practices about dispensing fiscalized substances and gender, age group, pharmacy type, work experience, university of graduation, and receiving training on epilepsy and antiepileptic drugs. Conclusion: The results implied that competency and experience are vital factors for the dispensing of tramadol. Contextually, the majority of the pharmacists evidently have the requisite competencies to provide high-quality and proper medical care, with regards to dispensing tramadol, which will minimize drug abuse and medication errors, and assist outpatients to manage their drugs containing fiscalized substances.

A new perspective: Practice-enhancing publications about the ambulatory care medication-use process in 2020

DISCLAIMER

In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

PURPOSE

This article identifies, prioritizes, and summarizes published literature on the ambulatory care medication-use process (ACMUP) from calendar year 2020 that can impact ambulatory pharmacy practice.

SUMMARY

The medication-use process is the foundational system that provides the framework for safe medication utilization within the healthcare environment and was reimagined to focus on new innovations and advancements in ambulatory pharmacy practice. The ACMUP is defined in this article as having the following components: transitions of care, prescribing and collaborative practice, accessing care, adherence, and monitoring and quality. Articles evaluating at least one step of the ACMUP were assessed for their usefulness toward practice improvement. A PubMed search covering calendar year 2020 was conducted in January 2021 using targeted Medical Subject Headings (MeSH) keywords and the table of contents of selected pharmacy journals, providing a total of 9,433 articles. A thorough review identified 65 potentially practice-enhancing articles: 14 for transitions of care, 19 for prescribing and collaborative practice, 10 for adherence, 6 for accessing care, and 16 for monitoring and quality. Ranking of the articles for importance by peers led to the selection of key articles from each category. The highest-ranked articles are briefly summarized, with a mention of why each article is important. The other articles are listed for further review and evaluation.

CONCLUSION

It is important to routinely review the published literature and to incorporate significant findings into daily practice. This article is the first to define and evaluate the currently published literature pertinent to the ACMUP. As healthcare continues to advance and care shifts to ambulatory settings, the ACMUP will continue to be a crucial process to evaluate.

Identifying key roles of the pharmacy technician in primary care settings

DISCLAIMER

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

PURPOSE

As the pharmacist's role expands, particularly in primary care practice settings, there is an opportunity for expansion of pharmacy technician duties to aid in administrative and clinical tasks that do not require the pharmacist's professional judgment. Identifying, defining, and expanding the roles of pharmacy technicians has been deemed a key part of the pharmacy practice model. These roles have been shown to enhance pharmacist efficiency and patient outreach; however, examples of the various innovative activities performed by technicians in the primary care setting are lacking in the literature.

METHODS

The duties of primary care pharmacist technicians were compiled and defined in 2 different healthcare systems. The role of the technician was separately implemented at each institution, and study designs and protocols were individually created and executed. One institution utilized a 4-round consensus-building process to systematically refine and codify tasks for a dictionary of duties. The second institution utilized a free-text survey, task documentation data in the electronic medical record, and a telephone discussion with the technicians.

RESULTS

Despite a lack of methods- and data-sharing between the 2 institutions, similar tasks were identified, including conducting patient outreach, assisting with medication affordability and access, providing patient education, managing referrals, and scheduling appointments. Differences in technician involvement were noted in areas such as prior authorization, care coordination meetings, and quality improvement projects.

CONCLUSION

Pharmacy technicians are a helpful, yet underutilized, resource in the primary care setting. Further exploration of technician roles is needed to determine the financial and clinical impact of expanding these roles.

Skills and practices of pharmacy staff for dispensing of drugs with fiscalized substances in drugstores and pharmacies

OBJETIVE

To evaluate the skills and practices of pharmacy staff during the dispensing of tramadol (drug with fiscalized substance) in drugstores and pharmacies in Medellin, Colombia.

METHODS

A cross-sectional study was performed. The simulated patient technique was used. The main outcomes included the information provided on the dispensed drug (tramadol), the use of tools to provide information, and the information provided on drug precautions and use recommendations.

RESULTS

We visited 305 drugstores and pharmacies. The average dispensing time was 2.3 min (SD 1.1 min). In nine drugstores and pharmacies (3.0%), tramadol was not dispensed because it was not in stock. In 17 drugstores and pharmacies (5.7%), the simulated patients were actively informed by the dispensing pharmacy staff; of these, 16 provided oral information and one provided oral and written information. Eight patients (2.7%) received information regarding tramadol use. However, 99% of patients were not informed about tramadol side effects such as dependence, sedation, or hypnosis, and none of the simulated female patients were informed on the precautions related to tramadol use during pregnancy or lactation.

CONCLUSIONS

Communication skills and appropriate practices of pharmacy staff are critical to patient self-care. However, this study shows their difficulty in counseling about precautions and use recommendations of drugs with fiscalized substances. These outcomes could inform future studies focusing on the rational use of these drugs in drugstores and pharmacies. It is necessary to improve the pharmacy staff competencies through continuing education programs, to facilitate access to information and training.

Impact of pharmacist-led selective audit and feedback on outpatient antibiotic prescribing for UTIs and SSTIs

PURPOSE

An estimated 30% of all outpatient antibiotic prescriptions in the United States are unnecessary. The Joint Commission, in 2016, implemented core elements of performance requiring antimicrobial stewardship programs (ASPs) to expand to outpatient practice settings. A study was conducted to determine whether pharmacist-led audit and feedback would improve antibiotic prescribing for urinary tract infections (UTIs) and skin and soft tissue infection (SSTIs) at 2 primary care practices.

METHODS

A retrospective, quasi-experimental study was conducted to evaluate antibiotic prescribing for patients treated for a UTI or SSTI at 2 primary care offices (a family medicine office and an internal medicine office). The primary objective was to compare the rate of appropriate antibiotic prescribing to patients treated before implementation of a pharmacist-led audit-and-feedback process for reviewing antibiotics prescribed for UTIs and SSTIs (the pre-ASP group) and patients treated after process implementation (the post-ASP group). Total regimen appropriateness was defined by appropriate antibiotic selection, dose, duration, and therapy indication in accordance with institutional outpatient empiric therapy guidelines. Secondary objectives included comparing rates of infection-related revisits and Clostridioides difficile infection between groups.

RESULTS

A total of 400 patients were included in the study (pre-ASP group, n = 200; post-ASP group, n = 200). The rate of total antibiotic prescribing appropriateness improved significantly, from 27.5% to 50.5% (P < 0.0001), after implementation of the audit-and-feedback process. There were also significant improvements in the post-ASP group vs the pre-ASP period in the individual components of regimen appropriateness: appropriate drug (70% vs 53%, P < 0.001), appropriate duration (83.5% vs 57.5%, P < 0.001), and appropriate therapy indication (98% vs 94%, P = 0.041). There were no significant between-group differences in other outcomes such as rates of adverse events, treatment failure, C. difficile infection, and infection-related revisits or hospitalizations within 30 days.

CONCLUSION

A pharmacist-led audit-and-feedback outpatient stewardship strategy was demonstrated to achieve significant improvement in outpatient antibiotic prescribing for UTI and SSTI.

Primary health care policy and vision for community pharmacy and pharmacists in Colombia

Colombia is a decentralized republic with a population of 50 million, constituted by 32 departments (territorial units) and 1,204 municipalities. The health system provides universal coverage and equal access to health care services to 95% of the population. Primary health care is seen as a practical approach that guarantees the health and well-being of whole-of-society. The National Pharmaceutical Policy (NPP, 2012) goal is “to develop strategies that enable the Colombian population equitable access to effective medicines, through quality pharmaceutical services (PS)”. There are 4,351 providers certified to deliver PS: 3,699 (85%) ambulatory and 652 (15%) hospital care. The goals for PS are: a) promoting healthy lifestyles; b) preventing risk factors arising from medication errors; c) promoting rational use of medicines; and d) implementing Pharmaceutical Care. There are a number of ways that ambulatory patients access medications: through intermediary private companies, public and private hospitals pharmacies, and retail establishments (drugstores and pharmacies). Intermediary private companies are similar to Pharmaceutical Benefits Management in the U.S. health system, and act as intermediaries between health insurers, pharmaceutical laboratories, and patients. Pharmacists are being employed by these companies and in health insurance companies managing, auditing and delivering rational use of medicines programs. In 2014 there were approximately 20,000 pharmacies and drugstores, (private establishments) where a significant number of prescription-only medicines are sold without medical prescription. Colombian laws allow personal without pharmacy education to be a “director” in these establishments, so the training and education of persons working in drugstores and pharmacies is an important challenge. There about 8,000 registered pharmaceutical chemists with 25% to 30% working in patient care. Since the 90´s, there are more favorable conditions for pharmacist’s participation and contribution to health system and patient’s health outcome. These environmental facilitators include: a) laws and regulations regarding pharmaceutical services (2005-2007), b) establishment of a NPP (2012), and c) opportunities associated with the consolidation of private health management companies providing health services with an interest in pharmaceutical services (since 1995). Finally, telepharmacy, comprehensive care routes for pharmaceutical services, and further strengthen of postgraduate training in pharmacy practice are future strategies to improve the pharmacy profession in Colombia. They provide an opportunity to influence the recognition and value of the pharmacist as the health care professional.

Report of the 2019-2020 AACP Student Affairs Standing Committee

The 2019-2020 Student Affairs Standing Committee addressed charges related to professional identity formation (PIF) in order to set direction and propose action steps consistent with Priority #3.4 of the AACP Strategic Plan, which states "Academic-practice partnerships and pharmacist-involved practice models that lead to the progress of Interprofessional Practice (IPP) are evident and promoted at all colleges and schools of pharmacy." To this end, the committee was charged to 1) outline key elements of PIF, 2) explore the relationship between formal curricular learning activities and co- or extra-curricular activities in supporting PIF, 3) determine the degree to which there is evidence that strong PIF is embedded in student pharmacists' educational experience, and 4) define strategies and draft an action plan for AACP's role in advancing efforts of schools to establish strong PIF in pharmacy graduates. This report describes work of the committee in exploring PIF and provides resources and background information relative to the charges. The committee offers several suggestions and recommendations for both immediate and long-term action by AACP and members to achieve goals related to integrating PIF into pharmacy education. The committee proposes a policy statement relative to the committee charges. Furthermore, the report calls upon the profession to develop a unified identity and incorporate support for PIF into pharmacy education, training, and practice.

Evaluation of the effects of a drug with fiscalized substance dispensation, health education, and pharmacovigilance continuing education program in Colombia drugstores and drugstores/pharmacies: study protocol of a multicenter, cluster-randomized controlled trial

Background

Health disorders, due to the use of drugs with fiscalized substances, including controlled substances, have become a common problem in Colombia. Multiple reasons can help explain this problem, including self-medication, since access to these drugs may be easier. Also, there is a lack of knowledge that these drugs are safer than illicit drugs. The use of these drugs without a valid medical prescription and follow-up can have negative consequences such as drug abuse, addiction, and overdose, and eventually, have negative health consequences. Pharmacy staff is essential to both assure the correct drug use and minimize prescription errors to help outpatients have better management of their pharmacotherapy. For this reason, it is necessary to increase key competencies like knowledge, skills, and attitudes in the pharmacy staff of ambulatory (outpatients) pharmacies.

Methods

This study is a prospective, cluster-randomized, parallel-group, multicenter trial of drugstores and drugstores/pharmacies (ambulatory pharmacies). The study is designed to determine the effectiveness of a drug with fiscalized substance dispensation, health education, and pharmacovigilance continuing education program in drugstores and drugstores/pharmacies. Pharmacy staff will be randomly selected and assigned to one of the study groups (intervention or control). The intervention group will receive a continuing education program for over 12 months. The control group will receive only general information about the correct use of complex dosage forms. The primary objective is to evaluate the effectiveness of a continuing education program to improve pharmacy staff competencies (knowledge, skills, and attitudes) to improve the ambulatory (outpatient) pharmacy services: dispensation, health education, and pharmacovigilance of drugs with fiscalized substances. The secondary outcomes include (a) processes associated with the management of drugs with fiscalized substances in drugstores and drugstores/pharmacies, including regulation compliance; (b) degree of implementation of ambulatory (outpatient) pharmacy services targeting these drugs in drugstores and drugstores/pharmacies; (c) patient satisfaction with such services; and (d) pharmacy staff satisfaction with the continuing education program.

Discussion

This clinical trial will establish whether providing a continuing education program for the adequate utilization of drugs with fiscalized substances improves pharmacy staff competencies regarding these drugs.

Trial registration

ClinicalTrials.gov NCT03388567. Registered on 28 November 2017. First drugstore or drugstore/pharmacy randomized on December 1, 2018.

Protocol version

0017102017MC

Identification of critical factors for forming collaborative relationships between physicians and pharmacists

PURPOSE

The purpose of this study was to identify and describe strategies that have successfully achieved collaboration among physicians and pharmacists providing comprehensive medication management (CMM) to support development of CMM services.

METHODS

A 2-phase, mixed-methods approach was employed to identify successful strategies for building pharmacist-physician relationships in primary care clinic settings. Phase I used a qualitative approach to identify strategies deemed successful in building relationships with physicians. An advisory group of pharmacists with experience building CMM practices assisted in the development of minimum criteria characterizing pharmacists as having strong collaborative relationships. Semi-structured interviews were conducted with 10 interviewees meeting established criteria. Researchers coded interview transcripts and identified the resulting strategies. Phase II employed a survey instrument to determine how frequently identified strategies are used and evaluate the relative level of perceived impact of each strategy, which was distributed to a national audience of pharmacists practicing in ambulatory care settings. Responses from pharmacists meeting prespecified criteria were included in the analysis.

RESULTS

Thirty-three strategies were identified and grouped into 8 themes. In phase II, 104 survey respondents met defined criteria and were eligible to endorse use of identified strategies and rate their relative influence.

CONCLUSIONS

Thirty-three strategies were identified and grouped into 8 themes to aid pharmacists practicing CMM in developing stronger collaborative relationships with physician colleagues. A national sampling found many of these strategies were employed by a majority of pharmacists, who had found them to be influential in creating collaborative relationships.

Exit-Knowledge About Dispensed Medications and Associated Factors Among Ambulatory Patients Attending Ayder Comprehensive Specialized Hospital, Mekelle, Ethiopia

BACKGROUND

Optimizing exit-knowledge of ambulatory patients is a major professional responsibility of pharmacists to reassure safe and cost-effective medicines use. The study assessed the exit-knowledge of ambulatory patients on their dispensed medications and associated factors.

PATIENTS AND METHODS

Institutional-based cross-sectional study was conducted among ambulatory patients who visited the outpatient pharmacy of Ayder Comprehensive Specialized Hospital (ACSH) from December 2019 to February 2020. Data were entered, cleaned, and analyzed using SPSS version 20. Binary logistic regression was employed to determine factors associated with exit-knowledge on their dispensed medications. At a 95% confidence interval (CI), p≤0.05 was considered statistically significant.

RESULTS

The study analyzed 400 patients; more than half of the participants were males (55.5%). The mean age of the participants was 41.3 years (mean ± standard deviation (SD), ±13). Less than half of the patients did not recall the name (44.5%) and major side effects (31.2%) of each medication. Furthermore, the overall sufficient knowledge was found to be 81%. Patients with single marital status were 4.454 times to have sufficient exit-knowledge of their dispensed medications than widowed (p=0.050) participants. Besides, patients who responded neutral clarity of pharmacist instruction had 4.745 times sufficient exit-knowledge than those who responded not clear (p=0.049). On the other hand, participants who got "enough" (p<0.0001) and "not enough" (p=0.006) information from the pharmacist were found to have a positive association with sufficient exit-knowledge than those who responded "I do not know".

CONCLUSION

The majority of patients had sufficient exit-knowledge of their dispensed medications. Martially single, neutral clarity of pharmacist's instructions and adequacy of the information delivered by the pharmacist were positively associated with participants' exit-knowledge of their dispensed medications. Hence, conducting a multicenter study, we recommend pharmacists to counsel their patients to underpin patients' knowledge of their dispensed medications.

ASHP Practice Advancement Initiative 2030: New recommendations for advancing pharmacy practice in health systems

Purpose

The process of updating the recommendations of the ASHP Practice Advancement Initiative (PAI) is described, and the new recommendations targeted toward the year 2030 are presented.

Summary

The process for updating ASHP recommendations for pharmacy-practice change included online surveys of pharmacists, pharmacy technicians, and other stakeholders; extensive discussions by an advisory panel, a strategic planning group, and participants in a town hall session at a national conference; an online public comment period; and final approval by the ASHP Board of Directors.

Conclusion

The guidance offered by the 59 updated PAI recommendations, which take into account environment trends that are likely to affect the pharmacy enterprise, will help health-system pharmacists in their ongoing pursuit of optimal, safe, and effective use of medicines.

Integration and compensation of pharmacists into primary care medical groups

OBJECTIVE

To demonstrate the expansion of an outpatient pharmacy program within a health system via annual wellness visits (AWVs) and disease state management patient encounters at outpatient medical groups.

SETTING

A referral-based pharmacist-managed ambulatory care center, a department of a hospital, and 4 primary care medical groups of a community practice hospital health system in Savannah and Pooler, Georgia, and Bluffton, South Carolina.

PRACTICE DESCRIPTION

St. Joseph's/Candler is a 714 bed, 2 hospital community practice heath care system located in Savannah, Georgia. The St. Joseph's/Candler Center for Medication Management (CMM) is a pharmacist-managed ambulatory care clinic that provides referral-based ambulatory care services in anticoagulation, diabetes, heart failure, tobacco cessation, transitional care, vaccinations, and wellness contracts for self-insured organizations, and has 147 referring physicians. Nurse Practitioners and Pharmacists evaluate and manage patients under their scope of practice and supervising medical director for the CMM. Pharmacists and Nurse Practitioners educate patients and collaborate with referring physicians for disease state management but do not carry prescriptive authority at CMM. CMM bills for services as a provider-based department of the hospital. CMM is recognized as an Anticoagulation Center of Excellence by the Anticoagulation Forum and is interventional with ambulatory care quality initiatives of the health system. Pharmacists in CMM are board-certified in ambulatory care provided by Board of Pharmacy Specialties and have completed a minimum of a 1-year post-graduate training program accredited by the American Society of Health-System Pharmacists. CMM has 4 off-campus satellite locations providing ambulatory care referral-based services. Since 2007, the CMM has primarily provided anticoagulation services via laboratory monitoring and management of warfarin.

PRACTICE INNOVATION

Pharmacists transitioned from provider-based departments of a hospital to outpatient primary care medical groups. This transition changed their job description and the model for reimbursement of the pharmacists' salaries. Four pharmacists were present 60 hours per week from January 2018 to August 2018, and 80 hours per week (2 full-time clinical pharmacist positions) from September 2018 to December 2018, to conduct AWVs and disease state management patient encounters. These pharmacists divided their time between a department of a hospital and a traditional medical group of the same health system.

EVALUATION

For calendar year 2018, 1770 AWVs and 468 disease state management patient care visits were provided exclusively by pharmacists to patients of the 4 primary care medical groups of this community practice health system. Patient visits for disease state management included diabetes, hypertension, hyperlipidemia, anticoagulation, and tobacco cessation.

RESULTS

For the calendar year 2018, 1770 AWVs and 468 disease state management patient visits were provided exclusively by pharmacists, under the direct supervision of physician, to patients of primary care medical groups.

CONCLUSION

This is an example of expanding direct patient care pharmacy services, within a health system, to primary care medical groups, without direct grant or university funding.

Students' Perceptions on a Business Plan Assignment for an Ambulatory Care Pharmacy Elective

Objective. To evaluate a business-centered assignment implemented in a pharmacy elective course at two different institutions and analyze student perceptions of the delivery platforms used and the value and utility of the assignment. Methods. The ambulatory care electives at Butler University and Samford University introduce students to the expanding role of the ambulatory care pharmacist, emphasizing business plan development for new ambulatory care pharmacy services. As part of the elective, students are asked to work in groups to complete a business plan for a new ambulatory care service of their choosing. A survey was conducted to assess student perceptions on the assignment. Results. Of the 58 students who completed the business plan assignment, 49 completed the survey and were included in the data analysis. Overall, 100% of Samford students and 97% of Butler students either strongly agreed or agreed that the business plan was an innovative assignment unlike others completed in the curriculum. Samford students strongly agreed (100%) that if asked by a future employer to develop a new pharmacy service, concepts learned from this assignment would be useful, compared to 59% of Butler students who felt this way. While both the web and written delivery platforms had identical learning outcomes, the written business plan was the approach that the majority of students were more comfortable using. Conclusion. The business plan assignment was used as a method to familiarize students with the process of developing new ambulatory care pharmacy services. Based on survey results, the students perceived this to be an innovative assignment that allowed them to feel confident in developing and communicating ambulatory care business plans. As the practice of ambulatory care pharmacy expands, assignments such as this can be included in the pharmacy curriculum to meet the need for teaching effective business strategies to future pharmacists.

Influence of an ambulatory care elective on career interest and perception of ambulatory care practice

BACKGROUND AND PURPOSE

Ambulatory care is a growing area of pharmacy practice. Previous studies have shown that an ambulatory care elective course may improve student understanding and interest in ambulatory care, but it is unknown if an elective course may impact a student's intended career choice. The purpose of this study is to assess the impact of an ambulatory care elective on student understanding of ambulatory care pharmacy practice, career interest, and interest in residency training.

EDUCATIONAL ACTIVITY AND SETTING

A three-credit-hour ambulatory care elective course was offered to pharmacy students in their third professional year of a four-year program at a private school of pharmacy in Fall 2015. All students in their third year of pharmacy school, including those enrolled in an ambulatory care elective course, were surveyed electronically at the beginning and end of the fall semester. Elective student responses were compared to non-elective student responses, and student responses were compared pre- versus post-semester within each group.

FINDINGS

Twenty-five of 72 non-elective students and 13 of 14 elective students responded to both surveys. Significantly more elective students felt they understood the daily responsibilities (p=0.003) and the role of the ambulatory care pharmacist (p = 0.001) in comparison to non-elective students post-semester. Interest in residency training or a career in ambulatory care pharmacy was not significantly different among groups pre- or post-semester.

SUMMARY

An ambulatory care elective course increased perceived understanding of ambulatory care pharmacy but did not have a significant impact on student interest in residency training or a career in ambulatory care.