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Applying the Evidence for Clinical Pharmacy Services to Pharmacy Practice . Provided by: Michael G. Liebl, BS, PharmD, BCPS Clinical Manager, Pharmacy Services The Methodist Hospital Houston, TX 77030 Pager: 281-735-5815 Phone: 713-441-6973 Email: mliebl@tmhs.org.

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applying the evidence for clinical pharmacy services to pharmacy practice

Applying the Evidence for Clinical Pharmacy Services to Pharmacy Practice

Provided by:

Michael G. Liebl, BS, PharmD, BCPS

Clinical Manager, Pharmacy Services

The Methodist Hospital

Houston, TX 77030

Pager: 281-735-5815

Phone: 713-441-6973

Email: mliebl@tmhs.org

program learning objectives
Program Learning Objectives

At the completion of this program, the participant will be able to:

  • Review the pharmacy and medical literature that evaluates clinical pharmacy services.
  • Identify key clinical pharmacy services demonstrated to improve morbidity and mortality outcomes.
  • Estimate the relative pharmacoeconomic benefit of certain clinical pharmacy services.
  • Relate the findings from the pharmacy and medical literature to an institution's provision of clinical pharmacy services.
disclosures
Disclosures:
  • No financial interest in any entity or individual cited in the presentation
  • Regarding disclosures for non-commercial content and conclusions within:
    • Active memberships in ACCP, ASHP, TSHP, GCSHSP & SCCM
    • My primary position: Manager, clinical pharmacy services
    • Previous role: Clinical pharmacist MICU & CVICU
    • Conducted and involved in clinical pharmacy research studies that evaluating the value of clinical pharmacy services
    • I have a significant (and financial) relationship with a clinical pharmacist
a timeline of our clinical pharmacy ancestry in the words of leaders of the movement
A timeline of our clinical pharmacy ancestry in the words of leaders of the movement

W. Arthur Purdum

...within the new minimum standard lies the key to our first objective: improving and extending the usefulness of the hospital pharmacist.

…Today we are still recognized as a complementary service department and we must continue our efforts until pharmacy is regarded asessential.

1950

slide5

Fast Forward to 2008 and ask the tough questions…

  • Is there an essential, established need for advanced clinical pharmacy services?
  • If yes, how great is the need? Is there a cost for not providing them?
  • What type of clinical services make the greatest difference?
  • What training is required to provide these services?
  • How many providers for a given institution?
  • Can the value of these services be measured?
  • Is the difference realized significant to stakeholders?
    • Patients
    • Administrators
    • Quality / regulatory agencies
    • Others
  • Has the call for advanced clinical pharmacy services been endorsed by: our profession, administrators, quality / regulatory agencies & patients?
slide6

So, where to begin…Is there an essential, established need for advanced clinical pharmacy service?...what is the problem or the void in healthcare?

medications estimated as the 4 killer annually
Medications:Estimated as the #4 Killer Annually

Heart disease 743,460 dead

Cancer 529,904 dead

Stroke 150,108 dead

Medications 137,000 dead

Pulmonary disease 101,077 dead

Accidents 90,523 dead

Pneumonia 75,719 dead

Lazarou, et al. JAMA 1998;279:1200-5

slide8

How common are ADRs & ADEs?

# of Events

(1000 pt days)

% of Patients with ADRs

Comments

Cornish P. Arch Int Med 2005; 165: 424-429. – Admission

% of Patients with error: 53%

38% with moderate to severe adverse event potential

Weiner B, Venarske JL, Yu M & Mathis K. Spine 2008;

% of meds with error pre: 62%

% of meds with error post: 39%

42% with moderate to severe adverse event potential

Bowman L. Can J of Hosp Pharm 1994; 5: 209-216. (Wishard, IN)

23.1%

10% severe

LOS 6.6 days; ~70% type ”A” Events

Classen DC.

JAMA. 1997; 277: 301-6

2.4%

Mortality 2%, LOS 2 days at a cost of $2,000/event

Moore N.

Br J Clin Pharmacol 1998; 3: 301-8.

5.6

NR

LOS 8.5 days;

7.6% of all hosp days

Lazarou J. JAMA 1998; 279: 1200.

(Meta-analysis of ADRs)

NR

6.7% (total)

0.32% (fatal)

Estimated as the 4th - 6th leading cause of death

Vargas E. CCM 2003; 31: 694-98.

NR

9.2%

LOS 3.9 days

Cullen D. CCM 1997; 25: 1289-97.

9.7

NR

NR

Holdsworth M. Arch Pediatr Adolesc Med 2003; 157: 60-65.

7.5

6%

LOS 15.3 days

Chaudhry S, Olofinboba K, J Gen Intern Med 2003; 18: 595-600.

NR

4.9%

1.9% of ADRs attributed to increased morbidity

Forester A. Ann Intern Med 2003; 138: 161-167.

NR

7.9%

Hospital readmissions due to medication events

slide10

How Hazardous Is Health Care?

Annual Cost: Lives Lost

Source: Roger Resar, MD (Mayo Clinic) IHI Symposium 2001

slide11

Neil M. Davis

“…After studying the Institute of Medicine’s To Err Is Human, a suggestion for improving might be that there should be a person who has expert knowledge about drugs and drug therapy to review the entire drug selection and monitoring aspects of patient care. In a world where there were no such people as pharmacists, they would have to be invented. Perhaps, on that planet, they would be called “medicationists”.

Well, our world does have drug experts. They are

called pharmacists, so there is no need to create

a new professional to fill that void.”

2000

clinical pharmacy services that impact patient care outcomes
Clinical Pharmacy Services That Impact Patient Care Outcomes
  • Specifics on individual services rendered
    • Admitting Pharmacist Services
    • Pharmacist Rounding
      • ICU
      • Acute Care
    • Anticoagulation Services
    • Pharmacokinetic Services
    • High-risk populations
      • Transplant
      • Oncology
admitting pharmacy services addressing medication errors from the start
Admitting Pharmacy Services:Addressing Medication Errors From the Start
  • Consistent finding of error rates
  • Consistent estimation of harm potential
  • Consistent finding of a meaningful improvement (reduction in error rate) with pharmacist involvement in the process

*Two phases reported for this evaluation: Pre-intervention & post-intervention

slide14

Clinical Pharmacist Impact: Inpatient Rounds

RRR: Relative Risk Reduction

ARR: Absolute Risk Reduction

NNT: Number needed to treat = [(1/ARR)x100]

how many clinical pharmacists does one need
How many clinical pharmacists does one need?
  • How few is too few?
    • Opportunity loss costs?
  • When are there too many?
    • Diminishing marginal return?
  • Where does one prioritize service?
slide22

Neil M. Davis

…The time needed for clinical activities can be gained from better utilization of pharmacy technicians, bar coding, automation and a well-designed, fully integrated CPOE. For some facilities, all of this will still not be enough to substantially reduce the error problem and more pharmacists will have to be hired.

…Institutions will have to attract and retain pharmacists…

Junior high and high school students must be exposed to the

benefits of pharmacy as a career choice to ensure that there

is an adequate pool of bright and motivated students.

2000

slide24

Donald E. Franke

...We see today that there are stirrings of a more objective approach towards sound drug therapy and…the pharmacist plays an increasingly important role.

…It seems to me that this trend which is gaining momentum constantly, offers great opportunities for pharmacists to increase our professional responsibilities through cooperative efforts with colleagues in the medical profession, we can increase our value as professionals benefiting not only to pharmacy but also to medicine, our hospital and patients. These are indeed goals to which we should strive.

…I am confident that the hospital pharmacist will…occupy an increasingly important position not only in the selection and procurement of pharmaceuticals but also as a valued consultant to the physician.

1952

slide25

Sister Mary John

…We are beginning a new era…more medical cases will increase the volume of drugs dispensed and paid for by a third party who will want prices to reflect costs. Hospital revenue must equal expenditures…so unnecessary expenditures must be curtailed.

...It is the pharmacist’s major duty to maintain rational therapeutics in his hospital. He must keep himself well informed about drugs so that he can withstand the flood of unsubstantiated claims often made for new products.

…To challenge scientifically, one needs an equality of knowledge. The doctor, so skilled in the basic sciences, is still vulnerable to the high pressured salesmanship of even nonpharmacists.

1957

pharmacoeconomics

Benefit

Cost

Pharmacoeconomics
  • Description and analysis of the costs of drug therapy to health care systems and society – it identifies, measures and compares the costs and consequences of pharmaceutical products and services.
  • Perspective is important…
    • Cost center
    • Department
    • Institution
    • System
    • Patient
    • Society
  • A few issues are black and white (red or green in the example);
  • Most are grey
recent cost of adverse events data icu
Recent Cost of Adverse Events Data (ICU)
  • Setting – 10 bed MICU and a 10 bed CCU at Brigham & Women’s Hospital & Harvard Medical School
  • Authors cited existing patient safety parameters already in place:
    • CPOE
    • Pharmacist on rounds
    • Nursing coverage nearly 1:1
    • Just culture
    • Intensivist physician staffing in place
slide31
Finding: Costs of the pharmacist were NOT overcome by savings from identifiable drug costs
  • Setting:
    • 480 bed Community Teaching Hospital
    • 12 bed MICU, 11 Bed Surgical ICU
  • Study Concerns:
    • Part time position – 2 hrs per day
    • Rotated days of the week
    • Rotated hours of the day (intentionally)
    • Excluded protocol management (intentionally)
    • No interventions to add new drugs for untreated diseases
    • TDM
    • No interactions with MDs on rounds

Am J Hosp Pharm. 1991 Oct;48(10):2154-7

pharmacy staffing associations and total costs of care in us hospitals

# of Dispensing Pharmacist / 100 Occupied Beds

# of Pharmacy Admin. / 100 Occupied Beds

# of Clinical Pharmacist / 100 Occupied Beds

Pharmacy Staffing Associations and total costs of care in US Hospitals
roi or cost to benefit ratio for clinical pharmacy services what should be expected
ROI or Cost to Benefit Ratio for Clinical Pharmacy ServicesWhat Should Be Expected?

Please write down a number

endorsements of clinical pharmacy services not a comprehensive list
Endorsements of Clinical Pharmacy Services:(Not a comprehensive list...)
  • ASHP & ACCP
  • SCCM – Standards for pharmacy services in the ICU that include various levels of clinical pharmacy activities: Fundamental, Desirable & Optimal
  • AHRQ – Several chapters (5, 7,8, & 9) on the benefit to quality and cost for hospitals in areas such as ADE reduction, Medication error reduction, Anticoagulation.
  • Society for Hospital Medicine (SHM) & ASHP Joint Position Paper
  • Infectious Diseases Society of America
  • The Joint Commission
  • UNOS
  • Leapfrog Group
where will the clinical pharmacists of tomorrow come from
Where will the clinical pharmacists of tomorrow come from?
  • What experience or training is required?
  • Who will train them?
slide36

Joe Smith

…Let me summarize this recommendation for an entry level residency program in hospital pharmacy. 1st training in clinical (general) practice becomes the focus of the program. 2nd a Pharm.D. degree should be a prerequisite for entry into the program. 3rd the training program should provide meaningful experience in the other important services and in the overall management of the department. 4th this generalist entry-level residency should be a prerequisite for advanced specialized residency programs. It is this level of training that we should set our sights on for all pharmacists who are preparing for a future in hospital pharmacy practice.

…Beyond this entry-level training program, there is a growing need for highly specialized clinical training programs. I believe that there is now a much greater demand for highly specialized clinicians than we can supply, and the demand will likely increase.

…The leaders of a clinical profession must be committed to, almost obsessed with, the idea of clinical practice. And, most important, they will need to project that idea into images that create excitement in other people about that activity.

1988

accp white paper
ACCP White Paper

Estimated Needs:

Increase to 7,500 residency slots up from 1,250 offered today in mostly general practice (PGY-1)

PGY2 offerings should increase similarly

an institutional case based application
An Institutional, Case-Based Application
  • Setting:
    • 1,300-bed Tertiary Care, Private Teaching Hospital
    • Adult medical / surgical population with oncology, transplant, psychiatry, women’s health and advanced heart failure populations
  • Teaching Affiliations
    • Medical, Nursing & Pharmacy Schools
  • Patient Payor Mix
    • Medicare / Medicaid: ~52%
    • Private pay: ~45%
slide39
Pharmacy Department Overview:
  • Highly automated: Robotics, automated dispensing cabinets, CPOE, electronic medication tracking system, and knowledge based medication administration pending
  • Technician driven order entry
  • Clinical pharmacy specialists in all major inpatient servicelines, nearly all with PGY1 and/or PGY2 training and several with board certification
  • Intensity of coverage M-F; 7AM – 5PM. Basic service commitments on the weekends
  • Code blue team response: 24/7
  • On-site Drug information Center & formulary management
  • PGY1 and PGY2 Pharmacy Residency Provider
  • Active Doctor of Pharmacy externship program
  • Active pharmacy and medical research initiatives
  • ACPE Provider
clinical pharmacist resource distribution

*

Clinical Pharmacist - Resource Distribution

*Ratio: Less 4.5 FTE for Weekend, Holiday & Vacation Coverage

slide41

Applying the Evidence:

Medication History Accuracy Improvements

Internal Data: Sirimaturos M, Venarske J & Yu M.

applying evidence tmh pharmacists clinical interventions 2006
Applying Evidence: TMH Pharmacists’ Clinical Interventions: 2006
  • Pharmacists documented approx 16,853 interventions in 2006
  • Intervention quality was sustained with a noted increase in the % of level two and level three interventions (up from 38% and 2% respectively)
  • Interventions by level:
  • Costs avoided per intervention by

significance level*:

    • Level 1 – $70
    • Level 2 – $500
    • Level 3 – $4,685
  • Projected costs avoided approximately: $6.2 Million dollars

Example: Patient identified with a platelet count decrease of greater than 50% from baseline & was maintained on heparin therapy. Pharmacist recommended antibody screen & treatment. Subsequent testing demonstrated patient was positive for Heparin antibodies and diagnosed with HIT.

*Cost avoided values derived from internal benchmarking, published pharmacoeconomic & ADE avoidance literature & medical malpractice claims higher in patients with preventable ADEs.

estimated clinical pharmacy consultation services provided
Estimated Clinical Pharmacy Consultation Services Provided*
  • Anticoagulation
    • Warfarin – 150 pts
    • Heparin – 130 pts
  • Falls Prevention – 60 pts
  • Polypharmacy – 30 pts
  • Discharge counseling – 200 pts
  • Pharmacokinetic – 2 pts
  • TPN – 25 pts
  • Renal dosing – 38 pts
  • Severe Sepsis – 20 pts
  • Other – 10 pts

*Based Upon Consult Orders Received per Month

in closing have we answered the questions
In closing, have we answered the questions?
  • Is there an essential, established need for advanced clinical pharmacy services?
  • If yes, how great is the need? Is there a cost for not providing them?
  • What types of clinical services make the greatest difference?
  • Can the value of these services be measured?
  • Is the difference realized significant to stakeholders?
    • Patients, Administrators, Quality / regulatory agencies
    • Others
  • Has the call for advanced clinical pharmacy services been endorsed by: our profession, administrators, quality / regulatory agencies & patients?
  • What training is required to provide these services?
  • How many providers for a given institution?
slide46

R. David Anderson

…pharmacists who are not in constant face-to-face contact with physicians, nurses & particularly patients where they are being treated & who are unable to see exactly how drugs work…are destined to know little more than a myriad of unorganized details.

…The pattern most idealized of a professional pharmacist would be one who has a close association with patients; a comprehensive awareness of previous medication habits; knows allergies, sensitivities, & idiosyncrasies; extracts information about them from charts, laboratory, x-ray, and other data; has access to drug-oriented information; is able to correlate that information with knowledge about the patient’s physiology & disease; & recommends to physicians, nurses, & others the proper course to follow where drugs are indicated. He emphasizes and insures safety and effectiveness of drugs.

…The hypothetical professional pharmacist would serve as a counselor, advisor, teacher… & patient care team member

…The model which comes closest to conformance with this professional ideal is the clinical pharmacist.

1976