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Clinical Pharmacy Services & ADAP Clients. Stephen Berk, RPh Acting Chief California AIDS Drug Assistance Program Unit. Clinical Pharmacy versus Pharmacy. Pharmacy Attention is on the drug Clinical Pharmacy Attention is on the patient or population receiving the drug. Traditional Pharmacy.

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clinical pharmacy services adap clients

Clinical Pharmacy Services & ADAP Clients

Stephen Berk, RPh

Acting Chief

California AIDS Drug Assistance Program Unit

clinical pharmacy versus pharmacy
Clinical Pharmacy versus Pharmacy
  • Pharmacy
    • Attention is on the drug
  • Clinical Pharmacy
    • Attention is on the patient or population receiving the drug
attention to patient or population receiving the medications
Attention to patient or population receiving the medications
  • Maximizing the clinical effect of medicines
    • Using the right medication at the right time
  • Minimizing the risk of adverse events
    • Educate about possible side effects
    • Monitor and improve adherence
  • Preserve scarce resource dollars
    • Less resistant virus
    • Less opportunistic infections
    • Possibly less side effects requiring additional therapy
why clinical pharmacy services
Why Clinical Pharmacy Services
  • Benefit to the Client
  • Benefit to the Program
  • Benefit to Society
benefits of service
Benefits of Service
  • Several studies indicate client – society benefits
    • Journal of the American Pharmacists Association (APhA) 2008
    • Aetna presentation at Academy of Manage Care Pharmacy Meeting 2008
    • Kaiser study in J. Acquired Immune Deficiency Syndrome 2007
slide9
APhA
  • Clients with multiple medical conditions and complex drug therapies
    • Significant improvement in drug therapy goals achieved
    • Drug problems resolved
    • Total annual health expenditures decreased
aetna study
Aetna Study
  • 2,400 clients identified as candidates for an adverse drug event – not disease specific
    • 15% drop in adverse drug events
    • Cost avoidance ranged from $476 to $2,506 per patient per year
      • Low touch intervention
        • Letter to prescriber
      • High touch intervention
        • Phone call to prescriber
kaiser study
Kaiser Study
  • Observational Study with two arms (1571 clients)
    • (A) sites with HIV trained pharmacist
    • (B) sites without HIV trained pharmacist
  • Outcomes Analyzed
    • Changes in plasma HIV RNA level
    • CD4 T-cell counts
    • Service utilization
      • Hospital days, ED visits, and office visits
kaiser study1
Kaiser Study
  • Results
    • Clients exposed to clinical pharmacist more likely to achieve HIV RNA level < 500 copies/mL at 12 months
    • At 24 months, practice size impacted results
      • Practices with >50 clients less impacted by clinical pharmacist
    • CD4 T-cell counts not significantly affected
kaiser study2
Kaiser Study
  • Conclusions
    • Positive association between clinical pharmacist and plasma HIV RNA control
    • Decline in office visits at 12 months
  • Limitations
    • Did not document interventions
    • Did not analyze impact on health care costs
medi cal hiv pharmacy pilot
Medi-Cal HIV Pharmacy Pilot
  • 10 HIV Specialty Pharmacies
    • 4 pharmacies from one organization
  • Reimbursed additional $9.50 per prescription
  • Measure results of specialized services
medi cal hiv pharmacy pilot1
Medi-Cal HIV Pharmacy Pilot
  • Services Offered
    • Evaluation of clients ability to adhere - 7
    • Identify & manage adverse drug reactions - 7
    • Management of side effects - 7
    • Tailor drug regimen to fit clients lifestyle - 6
    • Individualized counseling when overuse or under use is detected -6
medi cal hiv pharmacy pilot2
Medi-Cal HIV Pharmacy Pilot
  • Services offered
    • Refill reminders - 5
    • Individual appointments with pharmacist - 4
    • Adherence packaging - 4
    • Peer advocates - 4
    • Home visits or weekly phone call - 4
    • Other health assessments (blood pressure) - 4
    • Medication reminders (pagers, alarms) -3
medi cal hiv pharmacy pilot3
Medi-Cal HIV Pharmacy Pilot
  • First year evaluation (UCSD Skaggs School of Pharmacy and Pharmaceutical Sciences)
    • Higher medication adherence rates
    • Fewer excess fills
    • Fewer contraindicated regimens
    • More clients remained on single type ART strategy throughout 2005
clinical services in california
Clinical Services in California
  • Relatively New
    • Quarterly Clinical Update for Pharmacies
      • Pipeline Medications
      • Recent Approvals
      • Adherence Tips
    • Review of Prescription Claims
      • Duplicate Therapy
      • Drug Interactions
      • Contraindications
clinical services in california1
Clinical Services in California
  • New Drug Pipeline Monitoring
    • Determine Place in Therapy
    • Estimate Price
    • Project Usage
  • Clinical Drug Information for Medical Advisory Committee
  • Criteria for Medication Use
    • Input from PBM
    • Input from Medical Advisory Committee
california adap3
California ADAP
  • Future Plans
    • Pharmacy visits?
    • Partner with AETC
      • Pharmacist education ?
    • Use of ADAP Claims Data for Adherence Monitoring
    • Medication Therapy Management
      • Reimbursement ?
california limitations
California Limitations
  • Staff
    • Unit Chief’s (Pharmacist) Time Spent Doing Administrative Duties
    • Need to Hire Pharmaceutical Consultant
    • Need Research Staff to do Data Mining
  • Knowledge Level of Dispensing Pharmacies
    • Good in Specialized Pharmacies
    • Access to Care Issues if Limit ADAP Participation
  • Retrospective Review
    • Damage Already Done
barriers to providing services
Barriers to Providing Services
  • Geographic
    • Urban or Rural Location
  • Large Client Population
    • Over 31,000 Unique Clients Served in CY 2007
  • Large Pharmacy Network
    • Over 3,000 Statewide ADAP Participating Pharmacies
  • Financial
    • Program
    • Pharmacy
finally
Finally….
  • Ideal situation
    • Thorough pre-treatment counseling
    • Patient understands goals of therapy
    • How regimen relates to patient’s daily schedule and meals
    • Explain side effects, when they may occur and treatments for side effects
    • Pill boxes, pagers, timers, or medication maps
finally cont d
Finally…cont’d
  • On-going follow-up
  • Check in session 2 weeks after initiating therapy for new patients
    • Pill counts
    • Side effect management
  • Monitoring for lapses in adherence for “seasoned” patients
    • Pill or treatment fatigue
finally really
Finally…. (really)
  • In the Meantime
    • Educate providers (pharmacy and prescribers)
      • PPIs and Atazanavir
      • Efavirenz and women of child bearing age
      • Synchronize prescription fills
    • Use available data to improve care
      • Clients with low CD4 counts on PCP prophylaxis
      • Review for duplicate therapy
      • Review for appropriate prescribing practices