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Has Hospital Pharmacy Passed Its Peak?
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Purpose
The results of a survey to determine reasons for the slow adoption of prescribing authority by hospital pharmacists in the Canadian province of Alberta are presented.
Methods
A Web-based survey was conducted to elucidate pharmacist perspectives on additional prescribing authorization (APA), which permits independent prescribing by Alberta pharmacists who complete a peer-reviewed application process (at the time of the survey, only 52 hospital pharmacists had been granted APA). The survey elicited demographic data and practice characteristics and explored perspectives on APA and their influence on the decision to apply or not apply for APA.
Results
Approximately 500 pharmacists were invited to participate in the survey, and 314 (63%) responded and met the study inclusion criteria. The perceived relevancy and value of APA to respondents' practice activities and potential benefits such as increased efficiency appear to be important factors motivating pharmacists to apply for APA. A perception that the application process is too lengthy and concerns about potential drawbacks (e.g., increased liability risk, inability to fulfill patient follow-up and documentation requirements) appear to be strong influences on decisions to forgo pursuing APA.
Conclusion
Results of a survey of hospital pharmacists in Alberta suggest that APA is adopted more often by pharmacists whose primary focus is ambulatory care, those with higher levels of education, and those with more colleagues who also have APA. The perceived relevancy and value of APA to practice activities and the potential for increased efficiency and job satisfaction appear to be strong influences on decisions to seek APA.
A consistent feature of effective healthcare delivery systems is a strong and well-integrated primary care sector. This paper presents a framework that describes the key elements of high-performing primary care and the supports required to attain it. The framework was developed by the Quality Improvement and Innovation Partnership in Ontario (now part of Health Quality Ontario) to guide the process of primary care transformation. The first section of this paper presents and describes the framework, the second proposes implementation strategies and the third identifies system-level structures and policies needed to support primary care transformation. The framework has three components: (1) the major constituencies that primary care serves – patients, families and their local communities; (2) the desired outcomes of primary care (better health, better care, better value); and (3) the attributes that will enable primary care organizations to attain these outcomes. These attributes are a population focus, patient engagement, partnerships with health and community services, innovation, performance measurement and quality improvement and team-based care.Proposed transformation strategies include building system capacity and capability, ensuring access to resources, providing support from coaches and employing effective spread and sustainability strategies. Broader system-level structures and policies necessary to support and sustain a high-performing and continually improving primary care sector include clear goals; a comprehensive approach to performance measurement; systematic evaluation of innovation; funding incentives aligned with quality outcomes; a system of local primary care organizations; support for inter-professional teams; funding for research to inform primary care policy, management and practice; patient enrolment with primary care providers; and mechanisms to support coordination and integration.
1During the course of the study, several patients or their family members offered positive comments about the teambased clinical pharmacist services. These cases came to the authors’ attention during weekly investigator meetings and via pharmacists’ reflective journals, which were kept as a mecha nism to capture pharmacists’ experiences in working with the rounding medical team. 2 Since the overall research plan did not allow for a systematic evaluation of patient satisfaction with the service provided by pharmacists, it was decided to attempt to systematically capture comments from patients in another way, with a view to better understanding and demonstrating the impact of team-based delivery of clinical pharmacist services from the patient’s perspective. METHODS Information provided by the 2 team-based pharmacists involved in the COLLABORATE study was used to retrospec tively (i.e., near the end of the 1-year study period) identify patients who had demonstrated willingness to “act as a reference” for the study pharmacists as a result of the care provided during the study. This patient identification scheme was chosen because it was impossible to contact the entire population of patients who had interacted with the team-based pharmacist, since the requirement for patient consent had been waived in the original COLLABORATE study. Three potential patients were identified and were approached by telephone to participate in a face-to-face semistructured interview. One patient and her husband/ caregiver agreed to participate in the interview, and the pharmacist’s reflective journal was screened for any comments pertaining to this case. The interview was designed to let the patient and caregiver tell their versions of the events that occurred during the hospital stay, particularly their experience working with the pharmacist and the impact of the pharma cist’s care on the patient’s recovery and future ability to manage her medications. The study protocol was approved by the Ethics Review Board of the University of Alberta, and informed consent was obtained from the participants.
The primary care medical home has been promoted to integrate and improve patient care while reducing healthcare spending, but with little formal study of the model or evidence of its efficacy. ProvenHealth Navigator (PHN), an intensive multidimensional medical home model that addresses care delivery and financing, was introduced into 11 different primary care practices. The goals were to improve the quality, efficiency, and patient experience of care.
To evaluate the ability of a medical home model to improve the efficiency of care for Medicare beneficiaries.
Observational study using regression modeling based on preintervention and postintervention data and a propensity-selected control cohort.
Four years of claims data for Medicare patients at 11 intervention sites and 75 control groups were analyzed to compute hospital admission and readmission rates, and the total cost of care. Regression modeling was used to establish predicted rates and costs in the absence of the intervention. Actual results were compared with predicted results to compute changes attributable to the PHN model.
ProvenHealth Navigator was associated with an 18% (P <.01) cumulative reduction in inpatient admissions and a 36% (P = .02) cumulative reduction in readmissions across the total population over the study period.
Investing in the capabilities of primary care practices to serve as medical homes may increase healthcare value by improving the efficiency of care. This study demonstrates that the PHN model is capable of significantly reducing admissions and readmissions for Medicare Advantage members.
The veterans health care system administered by the U.S. Department of Veterans Affairs (VA) was established after World War I to provide health care for veterans who suffered from conditions related to their military service. It has grown to be the nation's largest integrated health care system.
As the system grew, a number of factors contributed to its becoming increasingly dysfunctional. By the mid-1990s, VA health care was widely criticized for providing fragmented and disjointed care of unpredictable and irregular quality, which was expensive, difficult to access, and insensitive to individual needs.
Between 1995 and 1999, the VA health care system was reengineered, focusing especially on management accountability, care coordination, quality improvement, resource allocation, and information management. Numerous systemic changes were implemented, producing dramatically improved quality, service, and operational efficiency. VA health care is now considered among the best in America, and the VA transformation is viewed as a model for health care reform.
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).
Continuity of care, equitable access, and quality and safety are major foci in health services management. The introduction of limited prescribing rights to pharmacists has the potential to reduce fragmentation within the health system, optimise medication management, improve continuity of patient care and improve patient access to medication.
Eight models for pharmacists' prescribing have been implemented internationally, varying in their dependency on protocols, formularies and collaboration with physicians. These have also been described using terms such as Supplementary Prescribing and Patient Group Directions.
Issues relating to practical implementation of pharmacists' prescribing include negotiation of national health policy, pharmacists' training and accreditation, liability, reimbursement and documentation.
This position paper concerns improving health care in the United States. Unlike previous highly focused policy papers by the American College of Physicians, this article takes a comprehensive approach to improving access, quality, and efficiency of care. The first part describes health care in the United States. The second compares it with health care in other countries. The concluding section proposes lessons that the United States can learn from these countries and recommendations for achieving a high-performance health care system in the United States. The articles are based on a position paper developed by the American College of Physicians' Health and Public Policy Committee. This policy paper (not included in this article) also provides a detailed analysis of health care systems in 12 other industrialized countries. Although we can learn much from other health systems, the College recognizes that our political and social culture, demographics, and form of government will shape any solution for the United States. This caution notwithstanding, we have identified several approaches that have worked well for countries like ours and could probably be adapted to the unique circumstances in the United States.
This is the final report of the Royal Commission on the Future of Health Care in Canada, first appointed by the Government of Canada on April 3, 2001.Taken together, the 47 recommendations contained in this report serve as a roadmap for a collective journey by Canadians to reform and renew their health care system. They outline actions that must be taken in 10 critical areas, starting by renewing the foundations of universal medicare in Canada.
To obtain an understanding of how community pharmacists self-describe their professional role, in order to begin understanding some of the assumptions underlying pharmacy culture.
Cross-sectional qualitative study.
Edmonton, Canada, and surrounding area.
115 community pharmacists.
Brief telephone interview.
Pharmacists' self-description/perception of their professional role and its relation to underlying assumptions of pharmacy culture.
100 pharmacists provided usable responses. The majority of pharmacists practiced in a community chain setting (76%) and within the city of Edmonton (81%). The median length of time in practice was 15 years. A total of 278 separate response items were obtained. Of these responses, 45% were categorized as product focused, 29% as patient centered, and 26% as ambiguous. The first response of 52 of the 100 pharmacists was a product-focused description of their role. Overall, in either their first or second response, 57% of the pharmacists used the term "dispensing" or dispensing-related terms to describe their professional role.
The results of this study seem to suggest that community pharmacists who participated viewed themselves primarily as "dispensers of medication," not patient-centered practitioners. Sustainable pharmacy practice change will be possible only if the current culture aligns with change initiatives. Our findings may suggest that pharmacists' self-perception of what they do and, perhaps by extension, the culture of pharmacy itself, could be important barriers to implementing practice change initiatives. We need to better understand the culture of pharmacy to foster meaningful practice change.
Background:
The roles of pharmacists in patient care have expanded from the traditional tasks of dispensing medications and providing basic medication counseling to working with other health professionals and the public. Multiple reviews have evaluated the impact of pharmacist-provided patient care on health-related outcomes. Prior reviews have primarily focused on in-patient settings. This systematic review focuses on services provided by outpatient pharmacists in community or ambulatory care settings. This is an update of the Cochrane review published in 2000.
Objectives:
To examine the effect of outpatient pharmacists' non-dispensing roles on patient and health professional outcomes.
Search strategy:
This review has been split into two phases. For Phase I, we searched the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register (January 1966 through March 2007). For Phase II, we searched MEDLINE/EMBASE (January 1966 through March 2008). The Phase I results are reported in this review; Phase II will be summarized in the next update.
Selection criteria:
Randomized controlled trials comparing 1. Pharmacist services targeted at patients versus services delivered by other health professionals; 2. Pharmacist services targeted at patients versus the delivery of no comparable service; 3. Pharmacist services targeted at health professionals versus services delivered by other health professionals; 4. Pharmacist services targeted at health professionals versus the delivery of no comparable service.
Data collection and analysis:
Two authors independently reviewed studies for inclusion, extracted data, and assessed risk of bias of included studies.
Main results:
Forty-three studies were included; 36 studies were pharmacist interventions targeting patients and seven studies were pharmacist interventions targeting health professionals. For comparison 1, the only included study showed a significant improvement in systolic blood pressure for patients receiving medication management from a pharmacist compared to usual care from a physician. For comparison 2, in the five studies evaluating process of care outcomes, pharmacist services reduced the incidence of therapeutic duplication and decreased the total number of medications prescribed. Twenty-nine of 36 studies reported clinical and humanistic outcomes. Pharmacist interventions resulted in improvement in most clinical outcomes, although these improvements were not always statistically significant. Eight studies reported patient quality of life outcomes; three studies showed improvement in at least three subdomains. For comparison 3, no studies were identified meeting the inclusion criteria. For comparison 4, two of seven studies demonstrated a clear statistically significant improvement in prescribing patterns.
Authors' conclusions:
Only one included study compared pharmacist services with other health professional services, hence we are unable to draw conclusions regarding comparisons 1 and 3. Most included studies supported the role of pharmacists in medication/therapeutic management, patient counseling, and providing health professional education with the goal of improving patient process of care and clinical outcomes, and of educational outreach visits on physician prescribing patterns. There was great heterogeneity in the types of outcomes measured across all studies. Therefore a standardized approach to measure and report clinical, humanistic, and process outcomes for future randomized controlled studies evaluating the impact of outpatient pharmacists is needed. Heterogeneity in study comparison groups, outcomes, and measures makes it challenging to make generalised statements regarding the impact of pharmacists in specific settings, disease states, and patient populations.
A patient-centered medical home (PCMH) demonstration was undertaken at 1 healthcare system, with the goals of improving patient experience, lessening staff burnout, improving quality, and reducing downstream costs. Five design principles guided development of the PCMH changes to staffing, scheduling, point-of-care, outreach, and management.
To report differences in patient experience, staff burnout, quality, utilization, and costs in the first year of the PCMH demonstration.
Prospective before and after evaluation.
Baseline (2006) and 12-month (2007) measures were compared. Patient and staff experiences were measured using surveys from a random sample of patients and all staff at the PCMH and 2 control clinics. Automated data were used to measure and compare change components, quality, utilization, and costs for PCMH enrollees versus enrollees at 19 other clinics. Analyses included multivariate regressions for the different outcomes to account for baseline case mix.
After adjusting for baseline, PCMH patients reported higher ratings than controls on 6 of 7 patient experience scales. For staff burnout, 10% of PCMH staff reported high emotional exhaustion at 12 months compared with 30% of controls, despite similar rates at baseline. PCMH patients also had gains in composite quality between 1.2% and 1.6% greater than those of other patients. PCMH patients used more e-mail, phone, and specialist visits, but fewer emergency services. At 12 months, there were no significant differences in overall costs.
A PCMH redesign can be associated with improvements in patient experience, clinician burnout, and quality without increasing overall cost.
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.
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.
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).
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.
Primary care pharmacists carry out clinical and administrative work directly for family doctors and primary care organisations. They are a relatively recent innovation and their role in the United Kingdom (UK)'s National Health Service (NHS) is still developing. The economic liberalization of the NHS in the 1990s seems to have provided a major stimulus for the growth of primary care pharmacy. The establishment of the new professional group was not linked to a deliberate plan or change in health policy with respect to pharmacist development. Primary care pharmacy practice is much more varied and flexible than traditional pharmacy practice in the community and hospitals. Standards and professional organisation for primary care pharmacy are slowly emerging. Modernization of the NHS is providing many new opportunities, which primary care pharmacists are well placed to take advantage of. Traditional community pharmacy faces many problems unless it can learn to develop alongside primacy care pharmacy. Pharmaceutical care is set to improve in the United Kingdom, but the precise nature of future services and providers remains uncertain.
We developed a model for the provision of clinical pharmacy services in United States hospitals in 2020. Data were obtained from four National Clinical Pharmacy Services database surveys (1989, 1992, 1995, and 1998) and from the American Health-System Association's 2000 Abridged Guide to the Health Care Field. Staffing data from 1998 indicated that 45,734 pharmacist and 43,836 pharmacy technician full-time equivalent (FTE) staff were employed in U.S. hospitals; 17,325 pharmacist FTEs (38%) were devoted to providing clinical pharmacy services. To provide 14 specific clinical pharmacy services for 100% of U.S. inpatients in 2020, 37,814 new FTEs would be needed. For a more realistic manpower projection, using an evidence-based approach, a set of five core clinical pharmacy services were selected based on favorable associations with major health care outcomes (mortality rate, drug costs, total cost of care, length of hospital stay, and medication errors). The core set of services were drug information, adverse drug reaction management, drug protocol management, medical rounds, and admission drug histories. Implementing these core clinical pharmacy services for 100% of inpatients in 2020 would require 14,508 additional pharmacist FTEs. Based on the current deployment of clinical pharmacists and the services they perform in U.S. hospitals, change is needed to improve health care outcomes and reduce costs. The average U.S. hospital (based on an average daily census of 108.97 +/- 169.45 patients) would need to add a maximum of 3.32 pharmacist FTEs to provide these core clinical services (if they were not provided already by the hospital). Using this evidence-based approach, the five selected core clinical pharmacy services could be provided with only modest increases in clinical pharmacist staffing.
The role of clinical pharmacists in the care of hospitalized patients has evolved over time, with increased emphasis on collaborative care and patient interaction. The purpose of this review was to evaluate the published literature on the effects of interventions by clinical pharmacists on processes and outcomes of care in hospitalized adults.
Peer-reviewed, English-language articles were identified from January 1, 1985, through April 30, 2005. Three independent assessors evaluated 343 citations. Inpatient pharmacist interventions were selected if they included a control group and objective patient-specific health outcomes; type of intervention, study design, and outcomes such as adverse drug events, medication appropriateness, and resource use were abstracted.
Thirty-six studies met inclusion criteria, including 10 evaluating pharmacists' participation on rounds, 11 medication reconciliation studies, and 15 on drug-specific pharmacist services. Adverse drug events, adverse drug reactions, or medication errors were reduced in 7 of 12 trials that included these outcomes. Medication adherence, knowledge, and appropriateness improved in 7 of 11 studies, while there was shortened hospital length of stay in 9 of 17 trials. No intervention led to worse clinical outcomes and only 1 reported higher health care use. Improvements in both inpatient and outpatient outcome measurements were observed.
The addition of clinical pharmacist services in the care of inpatients generally resulted in improved care, with no evidence of harm. Interacting with the health care team on patient rounds, interviewing patients, reconciling medications, and providing patient discharge counseling and follow-up all resulted in improved outcomes. Future studies should include multiple sites, larger sample sizes, reproducible interventions, and identification of patient-specific factors that lead to improved outcomes.
To determine if hospital-based clinical pharmacy services and pharmacy staffing continue to be associated with mortality rates.
A database was constructed from 1998 MedPAR, American Hospital Association's Annual Survey of Hospitals, and National Clinical Pharmacy Services databases, consisting of data from 2,836,991 patients in 885 hospitals. Data from hospitals that had 14 clinical pharmacy services were compared with data from hospitals that did not have these services; levels of hospital pharmacist staffing were also compared. A multiple regression analysis, controlling for severity of illness, was used.
Seven clinical pharmacy services were associated with reduced mortality rates: pharmacist-provided drug use evaluation (4491 reduced deaths, p=0.016), pharmacist-provided in-service education (10,660 reduced deaths, p=0.037), pharmacist-provided adverse drug reaction management (14,518 reduced deaths, p=0.012), pharmacist-provided drug protocol management (18,401 reduced deaths, p=0.017), pharmacist participation on the cardiopulmonary resuscitation team (12,880 reduced deaths, p=0.009), pharmacist participation on medical rounds (11,093 reduced deaths, p=0.021), and pharmacist-provided admission drug histories (3988 reduced deaths, p=0.001). Two staffing variables, number of pharmacy administrators/100 occupied beds (p=0.037) and number of clinical pharmacists/100 occupied beds (p=0.023), were also associated with reduced mortality rates.
The number of clinical pharmacy services and staffing variables associated with reduced mortality rates increased from two in 1989 to nine in 1998. The impact of clinical pharmacy on mortality rates mandates consideration of a core set of clinical pharmacy services to be offered in United States hospitals. These results have important implications for health care in general, as well as for our profession and discipline.
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