Pharmacists reducing medication risk in medical outpatient clinics: a retrospective study of 18 clinics

Benchmarking hospital clinical pharmacy practice using standardised key performance indicators (KPIs)

Background: Hospital pharmacy services support quality use of medicines and medication safety through clinical pharmacy activities such as medication reviews and patient education. These activities can be measured and monitored using evidence-based and standardised key performance indicators (KPIs), which highlight the value of pharmacy services. Standardisation of KPIs supports long-term benchmarking and inter- and intra-site comparisons to target key areas for improvement in clinical pharmacy services. Aim: To describe the type and frequency of clinical pharmacy activity across five hospitals within one metropolitan hospital district. Methods: Key Performance Indicator data were collected by pharmacists from five hospital sites at one metropolitan hospital district, in Queensland Australia. Data were collected over one week for the following clinical settings: inpatient, discharge, outpatient clinic, and the dispensary. Data were collected using a manual, paper-based data collection tool previously developed using a co-design process. Results: Across 11,215 inpatient encounters, hospital pharmacy services provided: best possible medication history (BPMH) within 24 h of admission: 69.5%; daily medication chart review: 57.2%; discharge education: 82.7%, discharge reconciliation: 88.2%; and provision of discharge medication record: 82.4%. Across 1,092 outpatient encounters, pharmacists documented BPMH for 33.3% of patients. Pharmacists identified a total of 5,009 drug-related problems (DRPs) across the data collection period, with the rate of identification highest in the outpatient clinic setting (64.8 per 100 patient reviews) followed by discharge (52.6 per 100 patient reviews) and then inpatient (48.1 per 100 patient reviews). Almost 20% of DRPs identified (n = 975) were high risk. Conclusion: Reporting and benchmarking clinical pharmacy activity through standardised KPIs supports opportunities to identify service improvements. Future research should focus on larger scale studies using routinely recorded data to monitor clinical pharmacy KPIs across all care settings.

Unplanned Rehospitalisation due to Medication Harm following an Acute Myocardial Infarction

INTRODUCTION

The contribution of medication harm to rehospitalisation and adverse patient outcomes after an acute myocardial infarction (AMI) needs exploration. Rehospitalisation is costly to both patients and the healthcare facility. Following an AMI, patients are at risk of medication harm as they are often older and have multiple comorbidities and polypharmacy. This study aimed to quantify and evaluate medication harm causing unplanned rehospitalisation after an AMI.

METHODS

This was a retrospective cohort study of patients discharged from a quaternary hospital post-AMI. All rehospitalisations within 18 months were identified using medical record review and coding data. The primary outcome measure was medication harm rehospitalisation. Preventability, causality, and severity assessments of medication harm were conducted.

RESULTS

A total of 1,564 patients experienced an AMI, and 415 (26.5%) were rehospitalised. Eighty-nine patients (5.7% of total population; 6.0% of those discharged) experienced a total of 101 medication harm events. Those with medication harm were older (p = 0.007) and had higher rates of heart failure (p = 0.005), chronic kidney disease (p = 0.046), chronic obstructive pulmonary disease (p = 0.037), and a prior history of ischaemic heart disease (p = 0.005). Gastrointestinal bleeding, acute kidney injury, and hypotension were the most common medication harm events. Forty percent of events were avoidable, and 84% were classed as "serious." Furosemide, antiplatelets, and angiotensin-converting enzyme inhibitors were the most commonly implicated medications. The median time to medication harm rehospitalisation was 79 days (interquartile range: 16-200 days).

CONCLUSION

Medication harm causes unplanned rehospitalisation in 5.7% of all AMI patients (1 in 17 patients; 6.0% of those discharged). The majority of harm was serious and occurred within the first 200 days of discharge. This study highlights that measures to attenuate the risk of medication harm rehospitalisation are essential, including post-discharge medication management.

Defining quality indicators, pharmaceutical care bundles and outcomes of clinical pharmacy service delivery using a Delphi consensus approach

BACKGROUND

Clinical pharmacy quality indicators are often non-uniform and measure individual activities not linked to outcomes.

AIM

To define a consensus agreed pharmaceutical care bundle and patient outcome measures across an entire state health service.

METHOD

A four-round modified-Delphi approach with state Directors of Pharmacy was performed (n = 25). They were asked to rate on a 5-point Likert scale the relevance and measurability of 32 inpatient clinical pharmacy quality indicators and outcome measures. They also ranked clinical pharmacy activities in order from perceived most to least beneficial. Based upon these results, pharmaceutical care bundles consisting of multiple clinical pharmacy activities were formed, and relevance and measurability assessed.

RESULTS

Response rate ranged from 40 to 60%. Twenty-six individual clinical pharmacy quality indicators reached consensus. The top ranked clinical pharmacy quality indicator was 'proportion of patients where a pharmacist documents an accurate list of medicines during admission'. There were nine pharmaceutical care bundles formed consisting between 3 and 7 activities. Only one pharmaceutical care bundle reached consensus: medication history, adverse drug reaction/allergy documentation, admission and discharge medication reconciliation, medication review, provision of medicines education and provision of a medication list on discharge. Sixteen outcome measures reached consensus. The top ranked were hospital acquired complications, readmission due to medication misadventure and unplanned readmission within 10 days.

CONCLUSION

Consensus has been reached on one pharmaceutical care bundle and sixteen outcomes to monitor clinical pharmacy service delivery. The next step is to measure the extent of pharmaceutical care bundle delivery and the link to patient outcomes.

Advanced-scope pharmacist roles in medical outpatient clinics: a cost-consequence analysis

BACKGROUND

There is a growing body of evidence that supports the clinical effectiveness of pharmacist roles in outpatient settings. However, limited studies have investigated the economic efficiency of advanced-scope outpatient pharmacist roles, particularly in the Australian setting. Assessing the overall costs and benefits of these outpatient pharmacist roles is needed to ensure service sustainability.

AIMS

To use a cost-consequence approach to evaluate the advanced-scope outpatient pharmacist roles across multiple clinic disciplines from the hospital perspective.

METHODS

A cost-consequence analysis was undertaken using data from a previous clinical-effectiveness study. All outpatient pharmacist consults conducted from 1 June 2019 to 31 May 2020 across 18 clinic disciplines were evaluated. Consequences from the pharmacist services included number of consults conducted, number of medication-related activities and number of resolved recommendations.

RESULTS

The overall cost to the hospital for the outpatient pharmacist service across all clinics was AU$1 991 122, with a potential remuneration of AU$3 895 247. There were 10 059 pharmacist consults undertaken for the 12-month period. Medication-related activities performed by pharmacists primarily included 6438 counselling and education activities and 4307 medication list activities. When the specialist pharmacist roles were added to the outpatient clinics, several health service benefits were also realised.

CONCLUSIONS

The addition of pharmacist roles to outpatient clinics can increase the cost of services; however, they also can increase medication optimisation activities. Future research should examine a societal perspective that includes broader cost and effectiveness outcomes. This study could justify the implementation of advanced-scope outpatient pharmacist roles in other Australian hospitals.

Economic evaluations of telepharmacy services in non-cancer settings: A systematic review

BACKGROUND

Telepharmacy is the provision of pharmacy services from a distance to a patient using telecommunications and other technologies. There has been limited research investigating the cost-effectiveness of telepharmacy services.

OBJECTIVE

To provide a comprehensive review and narrative synthesis of the available economic evidence on telepharmacy services in non-cancer settings.

METHOD

A systematic literature search of four databases including PubMed, Embase, CINAHL, and EconLit was undertaken to identify economic evaluations comparing telepharmacy services to standard pharmacy care. Abstracts and full texts were screened by two independent reviewers for inclusion against the eligibility criteria. Key economic findings were extracted from included articles to determine the cost-effectiveness of the reported telepharmacy services.

RESULTS

The review included six studies; two were cost-minimisation analyses, three were cost effectiveness analyses (CEA) and one study conducted both a CEA and cost-utility analysis. Telepharmacy services predominantly relied upon telephone modes of communication, with three that used remote patient monitoring. These services managed a variety of clinical situations which included newly initiated antibiotics, antiretroviral therapy management, and medications for chronic conditions, as well as hypertension management. Articles were of relatively high reporting quality, scoring an average of 83% on the Consolidated Health Economics Reporting Standards checklist. Four of the six studies reported that telepharmacy was less costly than usual care, with two that reported telepharmacy as cost-effective to the healthcare system according to a specified cost-effectiveness threshold.

CONCLUSIONS

Overall, this review demonstrates that there is emerging evidence that telepharmacy services can be cost-effective compared with standard care in non-cancer settings. Further research is needed to complement these findings, particularly reflecting the increased uptake of telehealth and telepharmacy services since the onset of the Coronavirus disease pandemic.

Benefits, challenges and contributors to the introduction of new hospital-based outpatient clinic pharmacist positions

Background

Pharmacists working within interprofessional teams in the outpatient setting are well placed to address medication-related problems before and after hospital admission. Therefore, exploration of these roles is warranted.

Objective(s)

To explore pharmacists' and other health professionals' perspectives of the impact of pharmacists working within interprofessional teams in outpatient clinics. Furthermore, we endeavoured to identify both the challenges and contributors to success with the introduction of pharmacists into these settings.

Methods

This qualitative study involved semi-structured interviews with both hospital outpatient clinic pharmacists and other clinic health professionals to gain an in-depth understanding of how the introduction of pharmacists into clinics impacted clinic processes, patient care, and relationships with other health professionals. Participants were recruited from the outpatient clinics who had recently added a pharmacist to their service. Participants involved in setting up the roles were invited to participate in a voluntary interview, the transcripts from which were analysed into themes and sub-themes using an inductive and deductive approach.

Results

A total of 34 staff were interviewed of which 68% were female and 74% were aged between 31 and 50 years. The cohort included 16 outpatient pharmacists, nine pharmacist team leaders, five clinic nurses and four clinic doctors (specialist consultant or registrar). Three overall themes were identified: the benefits, the contributors, and the challenges of introducing clinical pharmacy services to outpatient clinics. When establishing a clinic role, pharmacists' awareness, adaptability, and strong communication were shown to be key traits to building rapport and trustworthiness with the established clinic team.

Conclusions

When pharmacists are integrated into multidisciplinary outpatient clinics they and their colleagues believe that they provide benefits to the patients and the clinics. Decision makers need to be cognizant of factors that contribute to, as well as those that impede, the successful implementation of outpatient pharmacist roles.

Exploring factors of uneven use of telehealth among outpatient pharmacy clinics during COVID-19: A multi-method study

Background

To enable services to be provided at a distance during the COVID-19 pandemic, outpatient pharmacy services in Australia underwent near-immediate reform by moving to telehealth, including telephone and video consults.

Objective

To investigate how telehealth was used in a metropolitan outpatient pharmacy setting before and after the start of the COVID-19 restrictions and the various influences on the uptake of phone and video modalities.

Methods

A multi-methods approach was used including: (1) quantifying administrative activity data between July 2019 to December 2020 and, (2) semi-structured interviews with key stakeholders (n = 34).

Results

Activity data: Between July 2019 to December 2020 16,377 outpatient pharmacy consults were provided. Of these, 13,543 (83%) were provided in-person, 2,608 (16%) by telephone and 226 (1.4%) by video consult. COVID-19 impacted how these services were provided with telephone activity more than four-times higher in April 2020 than March 2020 and slight increases in video consults. Pharmacists have heavily favoured using the telephone despite the recommendation that video consults be used as the primary mode of contact and that telephone only be used when a video consult was not possible. As soon as COVID-19 restrictions eased, clinicians gradually returned to in-person appointments, maintaining some use of telephone and very limited use of video consult. Semi-structured interviews: Whilst clinicians recognised the potential benefits of video consults, challenges to routine use included the additional administrative and planning work required pre-consult, perceptions that patients were unable to use the technology, and the belief that in-person care was ‘better’ and that the telephone was easier.

Conclusion

Organisational strategies that encouraged the use of video over telephone (e.g. through financial incentives) did not appear to influence clinicians’ choice of care modality. Implementation studies are required to co-develop solutions to embed telehealth options into outpatient pharmacy settings that provide the best experience for both patients and clinicians.