Clinical Pharmacist Services Research Articles

Assessment and evaluation efficacy of a clinical pharmacist-led inpatient warfarin knowledge education program and follow-up at a Chinese tertiary referral teaching hospital

Background: Oral anticoagulation therapy with warfarin is used to prevent and to treat venous and arterial thrombosis and embolism. Its narrow therapeutic index should be monitored carefully in order to reach the desired outcomes. Objective: This study aims to evaluate the clinical pharmacist-led in-patient warfarin's knowledge education program and to assess a follow-up efficacy in a Chinese tertiary referral teaching hospital. Design and Setting: A cross-sectional and observational study was conducted at the Affiliated Hospital of Medical College of Nanjing University, a 1460-bed tertiary referral teaching hospital in Nanjing. Materials and Methods: One-on-one interview questionnaire was conducted among 47 Chinese patients who had undergone prosthetic valve replacement. Before the patient education program's implemented, at discharge time and 3 months, 6-9 months and 12 months after surgery were considered as time points. A previously validated 17-item questionnaire was used to measure the patient's knowledge level of warfarin and to assess and evaluate a follow-up efficacy of this patient education program run by a clinical pharmacist. Knowledge scores were compared using the Student's t-test or one-way analysis of variance. Main Outcome Measure: Patients' knowledge on the warfarin education program and warfarin knowledge score, drug therapy problems or bleeding complication events associated to warfarin therapy and evaluation of clinical pharmacist's service provided. Results: Patients mean age was 47.68 ΁ 9.70 years (range 23-67). The higher education strata had significantly higher warfarin knowledge scores (P < 0.05). In terms of hospital stay post-surgery, compared with other groups, patients with an average of 11-14 days, were found significantly and statically higher knowledgeable in warfarin (P < 0.05). The clinical pharmacist' service was found very satisfying f(80.85%). Conclusion: Chinese patients on warfarin therapy should benefit from periodic educational efforts reinforcing key medication safety information. Patient education is not a once-off procedure. A complete patient education program run by a clinical pharmacist in a Cardio-thoracic ward can considerably improve and enhance to reduce the hospital stays and significantly enlighten the role of the patient education in adherence to therapy.

Landscape of Medication Management in the Minnesota Patient-Centered Medical Home (PCMH)

Purpose: To describe the landscape of medication management within the patient-centered medical homes (PCMH) in the state of Minnesota.&#x0D; Methods: An electronic survey of care coordinators within PCMHs certified with the Department of Health in state of Minnesota was conducted. The survey and follow up were distributed by the Minnesota Department of Health. At the time the survey was distributed, there were 161 certified PCMHs in the state.&#x0D; Results: The final analysis included 21 respondents. Size, setting, and time as a certified PCMH varied between practices. PCMHs reported a higher percentage of patients enrolled at lower complexity tiers (35.0 percent at tier I and 40.4 percent enrolled at tier II), with PCMHs with clinical pharmacist services reporting slightly increased frequency of higher complexity patients. The composition of the care team varied from clinic to clinic, but all clinics were multidisciplinary with a mean of 5.8 different provider types listed for each clinic. Physicians were the most common providers of medication management across all settings, and one respondent reported that medication management services are not formally provided in his/her clinic. The presence or absence of a clinical pharmacist did not significantly influence care coordination time dedicated to medication-related activities. Respondents residing in a clinic with clinical pharmacist services reported a high level of satisfaction with pharmacist-provided services.&#x0D; Conclusion: The implementation of the PCMH model in many of the participating clinics was relatively recent and there remains much to be learned regarding the landscape of comprehensive medication management in the PCMH. The reported distribution of patients in complexity tiers suggests that clinics may use different strategies to determine resource allocation. Although the presence of a clinical pharmacist did not influence care coordination time dedicated, care coordinators valued services provided by clinical pharmacists.&#x0D; &#x0D; Type: Original Research

Process Indicators of Quality Clinical Pharmacy Services During Transitions of Care

The American College of Clinical Pharmacy charged the Public and Professional Relations Committee to develop a short white paper describing quality measures of clinical pharmacists' patient care services in transitional care settings. Transitional care describes patient movement from one health care setting or service to another. Care transitions are associated with an increased risk of adverse events for patients. Pharmacists play an important role in ensuring that medication errors and adverse events are minimized during these transitions, largely through the reconciliation of medications and assurance of continuity of care. Quality measures are often divided into three domains: structure, process, and outcome. Given the typical nature of the pharmacist's role, process indicators are best suited to evaluate quality clinical pharmacist services. However, process indicators relevant to pharmacists' activities are not yet fully described in the literature. The committee searched available literature describing quality measures that are directly influenced by the pharmacist during care transitions. This white paper describes these process indicators as quality measures of clinical pharmacists' services, identifies the transitional settings and activities to which they are most applicable, and provides the published sources from which indicators were derived. For process indicators that could not be found in published sources, we propose relevant measures that can be adapted for use in a given setting. As pharmacists become more involved in diverse and emerging patient care areas such as transitional care, it will be critical that they use these types of measures to document the quality of new services and reinforce the need for pharmacist participation during transitions of care.

Implementation of a comprehensive pharmaceutical care program for an underserved population

The implementation of a prescription benefit program for low-income patients emphasizing clinical pharmacist services and strict formulary control is described, with a review of program expenditures and cost avoidance. In 2006, University of Iowa Hospitals and Clinics (UIHC) launched a program to provide a limited prescription benefit to indigent patients under the IowaCare Medicaid demonstration waiver. Sudden dramatic growth in IowaCare enrollment, combined with sharp budget cuts, forced UIHC pharmacy leaders to implement creative cost-control strategies: (1) the establishment of an ambulatory care clinic staffed by a clinical pharmacy specialist, (2) increased reliance on an almost exclusively generic formulary, (3) collaboration with social services staff to help secure medication assistance for patients requiring brand-name drugs, (4) optimized purchasing through the federal 340B Drug Pricing Program, and (5) the imposition of medication copayments and mailing fees for prescription refills. Now in its seventh year, the UIHC pharmacy program has expanded indigent patients' access to pharmaceutical care services while reducing their use of hospital and emergency room services and lowering program medication costs by an estimated 50% (from $2.6 million in fiscal year 2009 to $1.3 million in fiscal year 2010). The UIHC ambulatory care pharmacy implemented a prescription program in collaboration with social service workers to address the medication needs of the state's low-income and uninsured patients in a fiscally responsible manner by managing purchasing contracts, revising a generic formulary, implementing copayments and mailing fees, and reviewing medication profiles.

Billing for pharmacists’ services provided to ambulatory care patients

In this issue of AJHP, Maldonado et al.1 bring to the fore important information on billing the Centers for Medicare and Medicaid Services (CMS) for patient care services provided by pharmacists. Based on my experience in advising numerous clinicians and administrators on creating financially sustainable clinical pharmacist services, I offer the following comments as additional background for and guidance to readers. The authors describe multiple methods for outpatient billing, including incident-to billing and facility or technical fee billing. (The terms facility fee and technical fee are often used interchangeably.) Readers should note that different CMS regulations apply to pharmacist incident-to billing in a physician-based outpatient clinic2 versus incident-to billing in a hospital-based outpatient clinic.3,4 In a physician-based clinic, only one bill is submitted for the provider’s professional fee, which includes a technical fee for overhead costs. However, in a hospital-based clinic, the professional fee and technical fee are submitted on two bills. Because hospitals have large variability in overhead costs, they are permitted to bill separately for these expenses. Hospital-based clinics are allowed to include the expense of a clinical pharmacist within the facility fee as a component of the clinic’s overhead expense.

A cost-effectiveness analysis of an in-hospital clinical pharmacist service

ObjectiveA randomised controlled study performed from 2007 to 2008 showed beneficial effects of a composite clinical pharmacist service as regards a simple health status instrument. The present study aimed to...

Medication Therapy Management in the Primary Care Setting

Objectives: To evaluate the effect of medication therapy management on chronic disease management and generic drug prescribing in the clinic setting. Methods: Private insurer initiates Pay-for-Performance (PFP) project for clinic-based pharmacists in Iowa and South Dakota (n = 9 clinics) in 2009. Each pharmacist was assigned ∽300 patients with at least 1 of 4 disease states (diabetes mellitus, hyperlipidemia, hypertension, and asthma). Pharmacists were expected to complete 2 medication reviews for each patient. The primary outcome was frequency of patients achieving goal levels: diabetes: hemoglobin A1c (A1c) <8%, low-density lipoprotein (LDL) <130 mg/dL, and blood pressure (BP) <140/80 mm Hg; hypertension: BP <140/90 mm Hg; hyperlipidemia: LDL <130 mg/dL; and asthma: percentage of persistent asthmatics on controller medication. Generic prescribing rates were evaluated for antihypertensives, cholesterol-lowering agents, proton pump inhibitors, and antidepressants. Results: A total of 827 patients at 3 clinics were included in the analysis. For diabetes, 77.1% had A1c <8%, 83.2% had LDL <130 mg/dL, and 76.3% had BP <140/80 mm Hg. For hypertension, 86.2% had BP <140/90 mm Hg. For hyperlipidemia, 80.6% had LDL <130 mg/dL. For asthma, 100% were on controller medication. One medication review was completed on 88.8% of patients. Generic prescribing rates ranged from 65.8% to 79.4%. Implications/Adaptability: A high percentage of patients achieved goal levels at clinics with clinical pharmacist services. A multidisciplinary approach to patient care may improve disease state management and medication cost savings.

Integration of a clinical pharmacist into the hematology–oncology clinics at an academic medical center

The development, implementation, and early experience with a program providing clinical pharmacist services at the hematology-oncology clinics of a university teaching hospital are described. With funding from a university research grant and other sources, a pharmacist was hired to launch a new program addressing four goals identified in a needs assessment: (1) improved management of supportive care, (2) enhanced education of patients receiving complicated chemotherapy regimens, (3) improved efficiency in the chemotherapy infusion unit, and (4) development of an experiential learning opportunity for pharmacy students and residents. The pharmacist hired to lead the ongoing program was a state-approved clinical pharmacist practitioner (CPP) who had authority to prescribe with physician oversight under established protocols. An oncology supportive care consultation service implemented by the CPP in collaboration with a nurse and a physician served 89 new patients in its first 18 months of operation; during that period the CPP made 186 interventions and wrote 136 prescriptions. The CPP also established a chemotherapy counseling service that provided more than 900 bill-able patient education sessions over 18 months. In addition, the CPP launched an effort to increase use of a rituximab rapid-infusion protocol among eligible patients. The creation of the new oncology pharmacist position has given dozens of pharmacy students and residents a new opportunity for interaction with oncology clinic patients and other health care team members. Integration of the services of a CPP into the hematology-oncology clinics has helped achieve goals set by physician, nursing, and pharmacy leaders.

Effects of a clinical pharmacist service on health-related quality of life and prescribing of drugs: a randomised controlled trial

ObjectiveTo evaluate the effects of a clinical pharmacist service on health-related quality of life (HRQL) and prescribing of drugs.MethodsA randomised controlled study was performed in two internal medicine wards. The...

Evaluation of the role of the critical care pharmacist in identifying and avoiding or minimizing significant drug-drug interactions in medical intensive care patients

Study Objective The aim of the study was to evaluate the impact of prospective review of significant drug-drug interactions (DDIs) occurring in medical intensive care unit (MICU) patients by the critical care pharmacist participating in patient care rounds on improvement of safer and more efficacious medication use. Study Design A prospective consecutive 10-week study was conducted in the MICU, St Luke's/Roosevelt Hospital Center (St Luke's site), New York, NY. This study compared baseline period when clinical pharmacist services were not provided with the period when each patient's profile was reviewed daily during MICU rounds and interactions were minimized. The study examined whether the presence of critical care pharmacist would decrease the number of significant DDIs in the MICU. Impact of decreasing presence of severe DDIs on length of stay (LOS) and discharge status was also evaluated. Results Having a pharmacist on rounds resulted in statistically significant decrease in number of clinically important interactions requiring therapy modification, rated D-X (Poisson regression B = −1.036; 95% confidence interval, −1.318 to −0.753; P < .01). The coefficient (−1.036) indicates the incidence rate ratio of 0.35, meaning that the presence of clinical pharmacist in MICU rounds decreased DDI rate by 65%. According to the multiple linear regression, lower number of DDIs was associated with shorter LOS ( P < .01). Inpatient mortality rate was lower in the intervention group compared with the preintervention group. Number of DDIs was not significantly associated with mortality based on simple regression ( P = .45) or multiple regression analysis ( P = .09). Conclusion Implementing a DDI screening procedure results in significantly lower number of important DDI in the MICU and shortens LOS.

Clinical Pharmacist Services Significantly Increase Low-Density Lipoprotein Cholesterol Goal Attainment in an Outpatient-Based Lipid Clinic

Clinical Pharmacist Services Significantly Increase Low-Density Lipoprotein Cholesterol Goal Attainment in an Outpatient-Based Lipid Clinic

Patient’s Perspectives on Team-Based Care by a Clinical Pharmacist: Case Report

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.

Medication safety in acute care in Australia: where are we now? Part 2: a review of strategies and activities for improving medication safety 2002-2008

BackgroundThis paper presents Part 2 of a literature review examining medication safety in the Australian acute care setting. This review was undertaken for the Australian Commission on Safety and Quality in Health Care, updating the 2002 national report on medication safety. Part 2 of the review examined the Australian evidence base for approaches to build safer medication systems in acute care.MethodsA literature search was conducted to identify Australian studies and programs published from 2002 to 2008 which examined strategies and activities for improving medication safety in acute care.Results and conclusionSince 2002 there has been significant progress in strategies to improve prescription writing in hospitals with the introduction of a National Inpatient Medication Chart. There are also systems in place to ensure a nationally coordinated approach to the ongoing optimisation of the chart. Progress has been made with Australian research examining the implementation of computerised prescribing systems with clinical decision support. These studies have highlighted barriers and facilitators to the introduction of such systems that can inform wider implementation. However, Australian studies assessing outcomes of this strategy on medication incidents or patient outcomes are still lacking. In studies assessing education for reducing medication errors, academic detailing has been demonstrated to reduce errors in prescriptions for Schedule 8 medicines and a program was shown to be effective in reducing error prone prescribing abbreviations. Published studies continue to support the role of clinical pharmacist services in improving medication safety. Studies on strategies to improve communication between different care settings, such as liaison pharmacist services, have focussed on implementation issues now that funding is available for community-based services. Double checking versus single-checking by nurses and patient self-administration in hospital has been assessed in small studies. No new studies were located assessing the impact of individual patient medication supply, adverse drug event alerts or bar coding. There is still limited research assessing the impact of an integrated systems approach on medication safety in Australian acute care.

Capturing Outcomes of Clinical Activities Performed by a Rounding Pharmacist Practicing in a Team Environment

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.

Medication Dosing and Renal Insufficiency in a Pediatric Cardiac Intensive Unit

Appropriate drug dosing in renal insufficiency is an important consideration to optimize therapeutic outcomes and to minimize toxicity. In this issue of the journal, Moffett and colleagues [4] remind health care providers of the clinical benefits of pharmacist involvement on drug dosing for patients with renal insufficiency in a pediatric cardiac intensive care unit. The authors adapted a wellknown list of drugs primarily excreted by the kidneys for patients with renal impairment. They noted that patients who required medication adjustments were significantly younger compared to those who did not require medication adjustment. Moffett et al. also report that clinical pharmacist consultation for prescribing drugs in the pediatric intensive care setting would be associated with shorter length of stay, lower costs, and lower rate of medication errors. Clinical pharmacist services in the hospital setting are proven to be beneficial. Such services are labor-intensive and require collecting patient data, calculating a creatinine clearance (CrCl) level, and contacting a physician to change the order to increase the likelihood of accurate medication selection and dosing based on an estimated CrCl. A rational approach to drug dosing in patients with renal impairment begins with a thorough history and physical examination. Particularly important is the history of previous drug allergy or toxicity and the use of concurrently prescribed or nonprescription drugs. Physical assessment should include estimating the extracellular fluid volume (ECFV); the presence of edema or dehydration alters drug dose. Body weight and height need to be measured, and the ideal body weight should be calculated and drug doses estimated accordingly. The renal excretion of drugs depends on glomerular filtration and renal tubular secretion and reabsorption. The glomerular elimination of drugs also depends on the molecular size and protein binding of the agent. Although protein binding decreases the filtration of drugs, it may increase the amount that the renal tubule secretes. When glomerular filtration is impaired by renal disease, the clearance of drugs that are eliminated primarily by this mechanism will be decreased and the plasma half-life of the drugs prolonged. The secretion of drugs eliminated by active transport systems in the renal tubule also will be affected in patients with renal disease. As the rate of CrCl decreases, drugs dependent on renal tubular excretion for elimination will be excreted more slowly. Furthermore, because the proximal tubular secretion of some agents is carrier mediated and capacity limited, concurrent use of multiple drugs eliminated by renal tubular secretion may saturate the transport system. Renal insufficiency alters both the disposition of drugs in the body (pharmacokinetics) and tissue responses to drugs (pharmacodynamics). If drugs or their metabolites are excreted by the kidneys, they can accumulate in patients with renal insufficiency and cause adverse effects. When the necessity for drug therapy has been established, renal function should be measured. Because the rate of elimination of drug excreted by the kidneys is proportional to the glomerular filtration rate (GFR), the serum creatinine or CrCl should be used to estimate renal function. The Schwartz equation can be used to estimate CrCl in children and adolescents [5]. However, estimating GFR from the serum creatinine assumes that renal function is stable and that the serum creatinine measurement is constant. With changing renal function, the serum creatinine level will no F. Assadi (&) Rush University Medical Center, Chicago, IL, USA e-mail: Ra-Id_Abdulla@rush.edu

Clinical Pharmacists and Inpatient Medical Care

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.

Potentially Inappropriate Prescribing in Ontario Community‐Dwelling Older Adults and Nursing Home Residents

To compare patterns of potentially inappropriate drug therapy prescribing in community-dwelling older adults and nursing home residents in Ontario, Canada. A retrospective cohort study using administrative databases. Ontario community and nursing home facilities. All 1,275,619 older adults aged 66 and older in Ontario (1,216,900 community-dwelling and 58,719 nursing home residents) who were dispensed at least one prescription from the comprehensive provincial drug plan in 2001. In Ontario, the provision of clinical pharmacy services is mandated in the nursing home setting. No comparable program exists for older adults in the community setting. Potentially inappropriate drug prescribing was compared between community-dwelling and nursing home residents in two categories: those to always avoid and therapies considered rarely appropriate to prescribe. Of the 1,275,619 adults in the cohort, nursing home residents were older (mean age+/-standard deviation=84.2+/-7.6 vs 75.0+/-6.5, P<.001), included more women (73.3% vs 57.7%, P<.001), had higher comorbidity scores (measured by the number of distinct drug therapies dispensed in the prior year (10.7+/-6.8 vs 7.2+/-5.7, P<.001) and Charlson comorbidity scores (1.4+/-1.6 vs 0.9+/-1.5, P<.001)) than community-dwelling individuals. Community-dwelling older adults were significantly more likely to be dispensed at least one drug therapy in the always avoid or rarely appropriate category than nursing home residents (3.3% vs 2.3%, P<.001). Using a logistic regression model that controlled for age, sex, and comorbidity (number of distinct drug therapies dispensed in the prior year), nursing home residents were close to half as likely to be dispensed one of these potentially inappropriate drug therapies as community-dwelling older adults (odds ratio=0.52, 95% confidence interval=0.49-0.55, P<.001). Potentially inappropriate drug therapy in the always avoid and rarely indicated categories is dispensed less often to nursing home residents than to older community-dwelling adults. Clinical pharmacist services, which are mandated in the nursing home setting, may be responsible for these differences in Ontario, Canada.

Effect of initiation, termination, and reinitiation of consultant clinical pharmacist services in a geriatric long-term care facility.

The effect of initiation, termination, and reinitiation of consultant clinical pharmacist services of drug regimen review and physician communication on patient drug use in a 72-bed geriatric long-term care facility was assessed at five points in time: initiation, termination, reinitiation, then 3 months and 3 years after reinitiation of services. Both times when the consultant was retained, drug use was cut almost in half (46.1% and 42.7%, respectively), with essentially the same number of established diagnoses per patient at each point in time. Conversely, before the consultant services were initiated, and when the consultants services were terminated, drug use was twice as great as when consultant pharmacist was retained. Regularly scheduled drugs increased 59%, and pro re nata (prn) drug increased 200% during the period between the termination and reinitiation of consultant services. There was also a lower admission, discharge, and death rate as well as higher hospitalization rate when the consultant was retained. It appears that the consultant clinical pharmacist has an impact on drug cost in long-term care facilities that is reversed when drug regimen review is removed and renewed when services are reinitiated.

Cost-Effective Clinical Pharmacy Services in a Veterans Administration Drop-In Clinic

Services provided by a clinical pharmacist in a Veterans Administration outpatient clinic are described. Patients who come to the drop-in clinic for prescription refill authorization or medication-related problems are seen by a pharmacist rather than by a physician. The pharmacist interviews the patient, reviews the medical records and prescription and nonprescription drug profile, assesses appropriateness of current drug use, and records findings in the progress notes. The pharmacist may recommend presciption refill, change of medication or dosage, discontinuation, referral to a physician or nurse practitioner, follow-up appointments, or laboratory tests. The physician must countersign the pharmacist's prescriptions, referrals, and requests for laboratory tests. The clinical pharmacist's services reduced demand for physicians' time, allowed patients direct access to the health-care provider suited to deal with medication-related problems, and provided improved continuity of care. Potential benefits are cost savings from discontinuation of inappropriate drug therapy and from use of a pharmacist instead of a physician. The number of hospital admissions related to adverse drug reactions also may be reduced.

Clinical Pharmacy Service Contributions on a Part-Time Basis

Staffing a majority of hospitals with full-time clinical pharmacists is an aim that will not be attainable for many years. In an effort to demonstrate an interim approach to clinical practice that could be applied to a large percentage of hospitals, a part-time clinical pharmacist's services were documented. Serving a teaching hospital with an average census of 97 patients, the pharmacist, with a 50 percent time allotment for clinical services, monitored 229 total admissions during an eleven week period. The majority of patients were on either a pulmonary medicine or urology service. The total number of actions taken as a result of pharmacy consultations was 106, with 70 percent of these being related to dosing problems. It was concluded that a pharmacist providing clinical services to a large patient population on a less than full-time basis can have a positive impact on drug therapy.