Prospectus on the economic value of clinical pharmacy services. A position statement of the American College of Clinical Pharmacy

Comparison of practice patterns between inpatient cardiology pharmacists with and without added qualifications in cardiology

BACKGROUND

There is a paucity of data comparing practice patterns between board-certified specialists with added qualifications in cardiology (AQCV) and cardiovascular pharmacists without these credentials.

PURPOSE

The purpose is to characterize differences in practice between inpatient pharmacists with and without AQCV.

METHODS

We conducted a multicenter, retrospective, cross-sectional, case-controlled survey. An AQCV pharmacist list was extracted from the Board of Pharmacy Specialties Web site. Hospitals with AQCV pharmacists comprised the case group. Hospitals were excluded if the AQCV pharmacists did not provide direct patient care, practiced in the outpatient setting, or were in a Veterans Affairs hospital. Each case hospital was matched to hospitals without an AQCV pharmacist in a 1:3 ratio (case:control) by region, cardiovascular discharges, and teaching hospital status. Institutions completed a survey characterizing their pharmacy services.

RESULTS

Fifty-six hospitals completed the survey (21 AQCV, 35 non-AQCV). More AQCV pharmacists participated on rounds (100% vs 82.9%, P = .04) and devoted more time performing administrative tasks (20.5% ± 15.3% vs 11.1% ± 8.1%, P = .001) than non-AQCV pharmacists. Conversely, AQCV pharmacists spent less time providing clinical care (52.4% ± 14.5% vs 66.2% ± 19.8%, P = .007), were less involved with drug protocol management (71.4% vs 91.4%, P = .05), and performed less order verification than non-AQCV pharmacists.

CONCLUSIONS

Practice patterns differ between inpatient pharmacists with and without AQCV. Further research is needed to determine whether AQCV credentialing improves patient outcomes and to delineate what specific tasks performed by inpatient cardiology pharmacists may improve patient outcomes.

Comparison of practice patterns between inpatient cardiology pharmacists with and without added qualifications in cardiology

BACKGROUND

There is a paucity of data comparing practice patterns between board-certified specialists with added qualifications in cardiology (AQCV) and cardiovascular pharmacists without these credentials.

PURPOSE

The purpose is to characterize differences in practice between inpatient pharmacists with and without AQCV.

METHODS

We conducted a multicenter, retrospective, cross-sectional, case-controlled survey. An AQCV pharmacist list was extracted from the Board of Pharmacy Specialties Web site. Hospitals with AQCV pharmacists comprised the case group. Hospitals were excluded if the AQCV pharmacists did not provide direct patient care, practiced in the outpatient setting, or were in a Veterans Affairs hospital. Each case hospital was matched to hospitals without an AQCV pharmacist in a 1:3 ratio (case:control) by region, cardiovascular discharges, and teaching hospital status. Institutions completed a survey characterizing their pharmacy services.

RESULTS

Fifty-six hospitals completed the survey (21 AQCV, 35 non-AQCV). More AQCV pharmacists participated on rounds (100% vs 82.9%, P = .04) and devoted more time performing administrative tasks (20.5% ± 15.3% vs 11.1% ± 8.1%, P = .001) than non-AQCV pharmacists. Conversely, AQCV pharmacists spent less time providing clinical care (52.4% ± 14.5% vs 66.2% ± 19.8%, P = .007), were less involved with drug protocol management (71.4% vs 91.4%, P = .05), and performed less order verification than non-AQCV pharmacists.

CONCLUSIONS

Practice patterns differ between inpatient pharmacists with and without AQCV. Further research is needed to determine whether AQCV credentialing improves patient outcomes and to delineate what specific tasks performed by inpatient cardiology pharmacists may improve patient outcomes.

Adherence With Therapeutic Regimens

There is an extensive literature regarding nonadherence with both therapeutic regimens and medication. This literature includes reviews of empirical research regarding the factors associated with nonadherence. Health care system, provider, and patient factors as well as the nature of the illness and therapeutic regimen all effect adherence rates. Different behavioral models for adherence counseling such as the Health Belief Model, the Theory of Reasoned Action, the Medication Interest Model, and Motivational Interviewing have also been reported in the research literature. This article will discuss the development of a brief model for patient counseling with specific techniques illustrated for pharmacists based on empirical findings that have demonstrated effectiveness in the adherence research literature. In addition, the article will address the measurement of the economic impact of medication nonadherence and propose a framework for assessing the cost-effectiveness of pharmacist counseling to increase adherence. The problem of nonadherence has significant effects upon health care expenditures through increase in physician’s visits, emergency department incidents, rehospitalizations, and nursing home readmissions. Thus, the overall goal is to assist the pharmacist in developing a brief adherence counseling program in community pharmacy and evaluating the economic feasibility of the intervention demonstrating the value-added proposition of pharmacist intervention.

Effects of Smartphones on Pharmacist-Physician Clinical Communication

Background:

Clinical pharmacist interventions are associated with improved patient outcomes and cost savings. Expanded interprofessional communication strategies may improve the efficiency and quality of the communication of these interventions.

Objective:

To determine the impact of smartphone device use on pharmacists' efficiency when communicating clinical interventions and to determine factors related to smartphone use that improve and impede communication.

Methods:

A prospective, 2-phase, observational study was completed. In phase 1, work shadowing observations involved general internal medicine (GIM) pharmacists who communicated interventions to a physician's smartphone (BlackBerry device) and multiorgan transplant (MOT) pharmacists who used traditional modes of communication (paging, phone call, face-to-face). On each ward, various aspects of the interventions were documented for a total of 20 hours. In phase 2, 10 interviews were conducted with GIM pharmacists and physicians to gain their perspectives on BlackBerry device communication.

Results:

In phase 1, no significant difference was found in median time to resolution (order change or drug information response given) between accepted interventions from the smartphone group (15.5 minutes) versus traditional modes of communication in the GIM group (4 minutes) and the MOT group (8.5 minutes) (p = 0.74). In phase 2, themes that emerged across the different clinical groups included perceived improvements in communication processes (efficiency, decreased wait times, and triaging of issues), concerns for potential miscommunication (use of tone in the emails), and recommendations regarding BlackBerry best practices (dealing with urgent/nonurgent issues and establishment of pharmacist-physician interprofessional relationships).

Conclusions:

Despite no significant difference in median time to resolution of pharmacists' interventions communicated through physician BlackBerry devices compared to traditional modes, the majority of interviewees perceived this device to be a positive communication tool resulting in improved efficiency of team communication.

Therapeutic drug and biochemical monitoring in a community pharmacy: Part 1

A therapeutic drug and biochemical monitoring service within the primary health care sector could provide positive patient outcomes. We have evaluated the possibility of measurements being made by a community pharmacist. Simultaneous blood samples were taken from a finger prick and vein of 55 patients attending a hospital outpatient clinic. The plasma drug concentrations (digoxin, carbamazepine, phenytoin and theophylline) and biochemical parameters (creatinine, potassium and urea) of these finger prick and venous samples were measured in a community pharmacy using the Ames Seralyzer and Clinimate systems. Similar measurements of the venous samples were made by the biochemistry department of a local hospital. There was no significant difference between the concentrations of the two samples (finger prick and venous) measured in the community pharmacy or between the community pharmacy measurements and those carried out by the hospital biochemistry department. External and internal quality control by the community pharmacist was satisfactory. Interpretation of the measured drug concentrations showed that optimal dosing was achieved in only 58.3, 33.3, 50.0 and 28.3 per cent of patients prescribed carbamazepine, digoxin, phenytoin and theophylline, respectively. Interpretation of biochemical concentrations showed that 38.9 per cent of the patients monitored were either hypo- or hyper-kalaemic; 80 per cent of the monitored patients taking renally excreted drugs required a change in their drug management. Although the patients in this study were attending a hospital outpatient clinic, the results highlight the potential benefit of a therapeutic drug and biochemical monitoring service within the primary health care sector.

Economic effects of clinical pharmacy interventions: a literature review

PURPOSE

Economic evaluations of clinical pharmacy interventions are reviewed.

SUMMARY

A variety of clinical pharmacy interventions have been assessed, but the body of evidence relating to any particular type of intervention is small. Cost-saving interventions comprise a small percentage of clinical pharmacy interventions, but they generated substantial savings. Clinical pharmacists provided added value by participating in multidisciplinary teams attending rounds. Clinical pharmacy interventions reduced preventable adverse drug events and prescribing errors, thereby yielding savings related to cost avoidance. Interventions relating to antibiotic therapy lowered costs of care without adversely affecting clinical outcomes. The results of cost-benefit analyses suggested that general clinical pharmacy interventions are associated with cost savings. Most economic evaluations of clinical pharmacy interventions suffered from a number of methodological limitations relating to the absence of a control group without clinical pharmacy interventions, limited scope of costs and outcomes, focus on direct health care costs only, exclusion of pharmacist employment cost, use of intermediate outcome measures, exclusion of health benefits, and absence of incremental cost analysis. Some avenues for designing future economic evaluations include the use of a control group, detailed descriptions of the interventions provided, evaluations conducted from a societal perspective, consideration of patients' health benefits when assessing economic effect of interventions and hospital costs, and the inclusion of sensitivity and incremental analyses.

CONCLUSION

Most pharmacoeconomic evaluations of clinical pharmacy interventions demonstrated limitations in their methodological quality and applicability to current practice. Future evaluations should use a comparative study design that includes the incremental cost-effectiveness or cost:benefit ratio of clinical pharmacy interventions from a societal perspective.

Evidence of the economic benefit of clinical pharmacy services: 1996-2000

We sought to summarize and assess original evaluations of the economic impact of clinical pharmacy services published from 1996-2000, and to provide recommendations and methodologic considerations for future research. A systematic literature search was conducted to identify articles that were then blinded and randomly assigned to reviewers who confirmed inclusion and abstracted key information. Results were compared with those of a similar review of literature published from 1988-1995. In the 59 included articles, the studies were conducted across a variety of practice sites that consisted of hospitals (52%), community pharmacies and clinics (41%), health maintenance organizations (3%), and long-term or intermediate care facilities (3%). They focused on a broad range of clinical pharmacy services such as general pharmacotherapeutic monitoring (47%), target drug programs (20%), disease management programs (10%), and patient education or cognitive services (10%). Compared with the studies of the previous review, a greater proportion of evaluations were conducted in community pharmacies or clinics, and the types of services evaluated tended to be more comprehensive rather than specialized. Articles were categorized by type of evaluation: 36% were considered outcome analyses, 24% full economic analyses, 17% outcome descriptions, 15% cost and outcome descriptions, and 8% cost analyses. Compared with the studies of the previous review, a greater proportion of studies in the current review used more rigorous study designs. Most studies reported positive financial benefits of the clinical pharmacy service evaluated. In 16 studies, a benefit:cost ratio was reported by the authors or was able to be calculated by the reviewers (these ranged from 1.7:1-17.0:1, median 4.68:1). The body of literature from this 5-year period provides continued evidence of the economic benefit of clinical pharmacy services. Although the quality of study design has improved, whenever possible, future evaluations of this type should incorporate methodologies that will further enhance the strength of evidence of this literature and the conclusions that may be drawn from it.

The critical care pharmacist: an essential intensive care practitioner

Clinical pharmacy services in the critical care setting have expanded dramatically and include assisting physicians in pharmacotherapy decision making, providing pharmacokinetic consultations, monitoring patients for drug efficacy and safety, providing drug information, and offering medical education to physicians, nurses, and patients. Measurable clinical effects of these services include reduced drug errors and adverse drug events, decreased morbidity and mortality rates, and a positive pharmacoeconomic impact by decreasing overall health care costs.

Practice-based research: lessons from community pharmacist participants

We designed this project to determine community pharmacists' opinions regarding the challenges and motivations of their recent participation in a pharmacy practice-based research study At the conclusion of a randomized, multicenter study, 87 community pharmacist-investigators were sent a questionnaire that explored four areas: motivating factors to participate, barriers to participation, communication tools used by study coordinators, and design issues for future studies. Fifty-eight (67%) completed questionnaires were returned. Key factors motivating participation in the study were desire to improve the profession and opportunity to learn. Time was the greatest barrier to participation. Pharmacy practice-based research has two distinct advantages. First, it translates clinical knowledge into direct application in the community. Second, it provides needed data to demonstrate the value of enhanced pharmacy practice. Thorough understanding of pharmacists' opinions is necessary to optimize the design of future studies.

Methods to assess the economic outcomes of clinical pharmacy services

Studies that demonstrate the clinical and economic burden of drug misadventures have been published. The economic burden of drug misadventures likely exceeds $100 billion annually in the United States alone. Clinical pharmacy services (CPS) have been shown to reduce negative clinical outcomes and costs of drug therapy. Pharmacy practitioners and pharmacy managers need to demonstrate the impact of CPS at the local level and present the value to financial decision-makers to gain support for implementation, continuation, and/or expansion of those services. The basic model of an economic evaluation includes measurement of both costs and consequences of a service and of an alternative for comparison. Strategies for economic assessments include the generalization from previously published literature, use of modeling techniques, and measurement of actual costs and consequences of an existing service. Guidelines for conducting an economic assessment are widely available. Pharmacy practitioners and managers should use these methods of assessing economic outcomes of CPS and, at the same time, develop relationships and skills to effectively communicate the value of those services so as to ensure long-term success.

Evaluating prescriptions for the elderly: drug/age criteria as a tool to help community pharmacists

OBJECTIVES

To use drug/age criteria to determine (1) the prevalence of dispensing of drugs potentially inappropriate for use in elderly patients; (2) the dispensing rate of individual drugs considered potentially inappropriate for use in elderly patients; (3) the association between selected patient characteristics and the prevalence of potentially inappropriate drug dispensing.

DESIGN, SETTING, PARTICIPANTS

A secondary database of 6,380 new prescription orders dispensed to patients of all ages in ambulatory pharmacies in a mid-western state was used retrospectively for the analysis. A total of 1,530 (23.9%) of the new prescription orders were dispensed to 1,185 elderly patients.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Name, strength, and daily dose of each drug dispensed were compared with drug/age criteria to determine whether a dispensed drug was inappropriate for use in elderly patients. The association of the rate of dispensing of potentially inappropriate drugs with characteristics of the elderly patients, including age, sex, race, number of comorbidities, and prescription drug insurance coverage type, was determined.

RESULTS

A total of 170 patients (14.3%) were dispensed potentially inappropriate medications. The three most common medications were propoxyphene and propoxyphene combinations, prescription and nonprescription antihistamines, and digoxin at doses > 0.125 mg/day. There was no statistically significant association between inappropriate drug dispensing and patient age, sex, race, number of comorbidities, and prescription drug insurance coverage type.

CONCLUSION

Pharmacists can use drug/age criteria as a tool for an initial check to assess the appropriateness of drugs used by the elderly. Elderly patients appear equally at risk of using potentially inappropriate medications regardless of demographic, disease, or insurance characteristics.

Expanding the roles of outpatient pharmacists: effects on health services utilisation, costs, and patient outcomes

BACKGROUND

In recent years pharmacists' roles have expanded from simply packaging and dispensing medications to working with other health care professionals and the public.

OBJECTIVES

To assess the effects of expanding outpatient pharmacists' roles on health services utilisation, the costs of health services, and patient outcomes.

SEARCH STRATEGY

We searched the Cochrane Effective Practice and Organisation of Care Group specialised register, MEDLINE, EMBASE, Pharmline, International Pharmaceutical Abstracts and reference lists of articles up to December 1995. We also searched the published abstracts of three meetings and hand searched five journals and two bibliographies.

SELECTION CRITERIA

Randomised trials, controlled clinical trials, controlled before-and-after studies and interrupted time series analyses of interventions comparing 1. Pharmacist services targeted at patients versus services delivered by other health professionals; 2. Pharmacist services targeted at patients versus no intervention; 3. Pharmacist services targeted at health professionals versus services delivered by other health professionals; and 4. Pharmacist services targeted at health professionals versus no intervention.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed study quality.

MAIN RESULTS

Fourteen studies were included involving more than 1991 patients. In the one study identified for comparison 1 the relative changes in professional outcome measures ranged from a 24% increase in clinic visits to a 16% decrease in hospital admissions. Relative differences in patient outcome measures were not statistically significant. Seven studies were identified for comparison 2. Four measured process of care and demonstrated decreases in health services utilisation from -67% for hospital admissions to -564% for total ambulatory care visits, as well as decreases in the numbers and costs of drugs compared to control patients. Five measured patient outcomes and consistently reported improvements in the targeted patient condition. In the one study identified for comparison 3 the intervention delivered by the pharmacist was less successful than that delivered by physician counsellors in decreasing inappropriate antibiotic prescribing. All six studies identified for comparison 4 demonstrated that the pharmacist intervention produced the intended effect on physician prescribing practices. These studies did not measure patient outcomes.

REVIEWER'S CONCLUSIONS

The limited number of studies analysed support the expanded roles of pharmacists in patient counselling and physician education. However, doubts about the generalisability of the studies, the poorly defined nature of the interventions tested, and the lack of studies including cost assessments and patient outcome data indicate that more rigorous research is needed to document the effects of outpatient pharmacist interventions.

Use of contingent valuation to place a monetary value on pharmacy services: an overview and review of the literature

An important goal for the pharmacy profession is to quantify the economic value of pharmacy services. The contingent valuation (CV), or willingness-to-pay method, offers one approach to valuing the benefits of pharmacy services. The potential advantage CV offers is that it reflects, in a single monetary amount, the entire range of attributes (both benefits and "nonbenefits") offered by the good or service being valued. This paper provides a brief overview of the CV method and reviews 10 published studies that used a willingness-to-pay question to place a monetary value on pharmacy services. Suggestions for other researchers wishing to use this method are provided.

Documenting the value of pharmacist interventions

The objectives of this study were to measure the incidence and types of pharmacist interventions performed in a community setting in two rural Texas counties; to assign some type of economic value to their services; and to compare these results with those of a previous study of interventions documented by pharmacy student externs and their preceptors. Pharmacists at four pharmacies in two Texas counties agreed to document their interventions on the next 1,500 new prescription orders brought to each pharmacy. The pharmacists first viewed a videotape training program and were instructed on the use of the Pharmacist Intervention Report. Each documented intervention was evaluated independently by a physician and a clinical pharmacist. The dollar value assigned to each of the pharmacists' interventions was the estimated direct cost of medical care avoided through the pharmacist's intervention to correct a prescribing problem. There were 47 interventions documented, representing 0.78% of the 6,000 prescription orders reviewed. The estimated value added by the interventions totaled about $20,000, or about $3.50 per prescription processed.

Drug dosing in renal insufficiency

Drug dosing in renal insufficiency needs to be individualized whenever possible to optimize therapeutic outcomes and to minimize toxicity. Although a number of published tables that provide dosing guidelines and nomograms exist to assist in dose modification, individualization of therapy should be based on pharmacokinetic principles whenever possible. The basis equations to estimate the pharmacokinetic parameters of clearance, volume of distribution, and half-life for intravenous drug administration of drugs with first-order kinetics are not difficult to understand and apply. Their use should be encouraged in patient care.

Value of community pharmacists' interventions to correct prescribing errors

OBJECTIVE

The purpose of this analysis was to estimate the economic value created by community pharmacists who routinely screen for and correct prescribing-related problems during the course of their dispensing activities.

DESIGN

Three expert judges evaluated the documented interventions of community pharmacists practicing in five states.

RESULTS

The judges agreed that 28.3 percent of the identified problems could have resulted in patient harm had the pharmacist not intervened to correct the problem. The direct cost of medical care that was avoided as a result of pharmacists' intervention activities was estimated to be $122.98 per problematic prescription, or +f42.32 per each new prescription order that was screened during the study.

CONCLUSIONS

Clinical pharmacy services can and do create significant value by enhancing the achievement of positive patient outcomes and by avoiding negative outcomes. Research to develop reliable methods for measuring and monitoring the value of clinical pharmacy services must continue. Mechanisms must be created to encourage and reward pharmacists who consistently provide services that add measurable value to patient care.

Relationships among prescription payment methods and interactions between community pharmacists and prescribers

OBJECTIVE

This research was performed to examine community pharmacists' interactions with prescribers and to determine if these interactions are related to payment method.

DESIGN

Randomly selected pharmacists (47 in chain pharmacies and 26 in independent pharmacies) collected data concerning prescriber interactions for a 40-hour period. These interactions were analyzed in terms of payment methods, prescriber acceptance, and types of information discussed.

RESULTS

Information concerning 730 interactions by 72 pharmacists was obtained. Payment methods were related to the frequency of interactions per pharmacist (p less than 0.01). There were higher percentages of interactions for self-pay (median 2.2 percent) and Medicaid (median 1.8 percent) prescriptions than for third-party fee-for-service (mode 0 percent) or capitation prescriptions (mode 0 percent). Type of information discussed was related to payment method. The vast majority of information provided by pharmacists (91 percent) was accepted by prescribers. The rate of acceptance was 97 percent for prescriber-initiated interactions versus 88 percent for pharmacist- or patient-initiated interactions (p less than 0.01).

CONCLUSIONS

Relationships between payment method and interactions were identified. These findings may be attributable to prescribing policies and reimbursement policies. Prescribing policies that restrict prescribers to a formulary may help make them become more adept at using those products; thus, they will make fewer prescribing errors. Reimbursement policies that require patients to consistently use a specific pharmacy (i.e., capitation) may help pharmacists become more familiar with the patient's prescription history. Therefore, interactions with prescribers are needed less frequently for these patients' prescriptions.