Pharmacist Monitoring Research Articles

Drug and Therapeutics Committees in Australia: expected and actual performance

1 This study describes stakeholders’opinions on Drug and Therapeutics Committees (DTCs) and measures the composition, activities and perceived effectiveness of DTCs in Australia.2 Focus groups explored the opinions of clinicians, consumers and administrators on the goals, objectives and strategies of DTCs.3 A national survey was sent to 306 hospitals to collect data on the composition, committee processes, goals, objectives, educational activities, policies and decision making of DTCs.4 Stakeholders believed the DTC should optimise therapeutic health outcomes for patients and economic outcomes for the hospital. Important objectives were availability of safe, efficacious and cost‐effective medicines, affordability of medicines and quality use of medicines.5 The national survey of DTCs found that over 92% of respondents had a DTC in their hospital. Composition was generally representational and most commonly included members from the disciplines of internal medicine, pharmacy and nursing. More than half the DTCs had executive authority although only 21% had an appeals mechanism.6 The most commonly cited issues for DTCs in 1994‐95 were quality drug use, drug policies and spending on high cost drugs.7 While access to clinical pharmacologists and specialist drug utilisation evaluation (DUE) pharmacists was poor, 71% of DTCs had access to DUE data of some sort. Guidelines (61%), prescribing restrictions (60%) and pharmacist monitoring (63%) were the most commonly used strategies to implement DTC policies and decisions. Audit‐feedback activities (61%) and drug bulletins (56%) were the most commonly used interventions.8 Available information for formulary decision making varied with small rural hospitals having access to significantly less information. The most commonly used information was availability of a therapeutic alternative (87%), efficacy (83%), cost (80%) and estimated usage (78%).9 On average DTCs reported an ability to implement 75% of decisions (range 0‐95%) with teaching hospitals perceived to perform better than other hospital types.10 This study reveals a high level of expectation for DTC activities and achievements. In Australia DTCs were involved in policy, education and management initiatives to promote best practice in therapeutics. Few committees appeared to have adequate resources to extend services to their wider community.

Drug and Therapeutics Committees in Australia: expected and actual performance

1. This study describes stakeholders' opinions on Drug and Therapeutics Committees (DTCs) and measures the composition, activities and perceived effectiveness of DTCs in Australia. 2. Focus groups explored the opinions of clinicians, consumers and administrators on the goals, objectives and strategies of DTCs. 3. A national survey was sent to 306 hospitals to collect data on the composition, committee processes, goals, objectives, educational activities, policies and decision making of DTCs. 4. Stakeholders believed the DTC should optimise therapeutic health outcomes for patients and economic outcomes for the hospital. Important objectives were availability of safe, efficacious and cost-effective medicines, affordability of medicines and quality use of medicines. 5. The national survey of DTCs found that over 92% of respondents had a DTC in their hospital. Composition was generally representational and most commonly included members from the disciplines of internal medicine, pharmacy and nursing. More than half the DTCs had executive authority although only 21% had an appeals mechanism. 6. The most commonly cited issues for DTCs in 1994-95 were quality drug use, drug policies and spending on high cost drugs. 7. While access to clinical pharmacologists and specialist drug utilisation evaluation (DUE) pharmacists was poor, 71% of DTCs had access to DUE data of some sort. Guidelines (61%), prescribing restrictions (60%) and pharmacist monitoring (63%) were the most commonly used strategies to implement DTC policies and decisions. Audit-feedback activities (61%) and drug bulletins (56%) were the most commonly used interventions. 8. Available information for formulary decision making varied with small rural hospitals having access to significantly less information. The most commonly used information was availability of a therapeutic alternative (87%), efficacy (83%), cost (80%) and estimated usage (78%). 9. On average DTCs reported an ability to implement 75% of decisions (range 0-95%) with teaching hospitals perceived to perform better than other hospital types. 10. This study reveals a high level of expectation for DTC activities and achievements. In Australia DTCs were involved in policy, education and management initiatives to promote best practice in therapeutics. Few committees appeared to have adequate resources to extend services to their wider community.

A Prospective Assessment of Pharmacist Monitoring of Patients with Renal Dysfunction Receiving Selected Drugs

ABSTRACT A pharmacist prospectively monitored 24 frequently prescribed drugs in 120 patients with renal dysfunction to determine appropriateness of dosing and cost assessment of recommendations. dosage criteria and a Drug Data Sheet outlining adverse effects and cautions for each drug were developed. A sample intervention letter was also developed to communicate patient specific drug related problems to the physician, with recommendations for change. All adult patients (>18 years old) admitted to the services of General Medicine, Urology, and Respirology who had a measured serum creatinine concentration greater than 95 μmol/L, were not undergoing peritoneal dialysis or hemodialysis, and were receiving one or more of the selected drugs were targeted. A total of 146 medication orders were screened during a six-week period. Fifty-one (35%) of these orders were inappropriate and required intervention. The acceptance rate of the pharmacist's interventions was 98%. A direct drug acquisition cost savings of $435.15 was realized for the six-week study period. Other populations and other drugs requiring dosage adjustment due to decreased renal function need to be examined. Monitoring of patients with renal dysfunction by a pharmacist improved the dosing of drugs and allowed a cost savings. RESUME Un pharmacien a effectue un controle prospectif de 24 medicaments couramment prescrits chez 120 patients atteints d'insuffisance renale, afin d'evaluer la justesse de la posologie et les couts relatifs aux recommandations. Des criteres posologiques et une « Feuille de donnees sur les medicaments » decrivant les effets indesirables et les mises en garde pour chaque medicament ont ete elabores. Une lettre d'intervention a aussi ete mise au point pour communiquer au medecin tout probleme pharmacotherapeutique particulier a un patient et les recommandations afferentes. Tous les patients adultes (> 18 ans) admis au departement de medecine generale, d'urologie ou de pneumologie et dont les concentrations seriques de creatinine etaient superieures a 95 μmol/L, qui ne subissaient pas d'hemodialyse ou de dialyse peritoneale, et qui recevaient un des medicaments choisis ou plus, etaient cibles. En tout, 146 demandes d'execution d'ordonnance ont ete controlees sur une periode de six semaines et 51 (35 %) de ces demandes n'etaient pas adequates et necessitaient l'intervention du pharmacien. Le taux d'acceptation des interventions du pharmacien, etait de 98 %. Des economies de couts d'acquisition directes totalisant 435,15 dollars ont ete realisees au cours de cette periode de six semaines. En conclusion, d'autres populations de patients et d'autres medicaments qui necessitent un ajustement posologique en raison d'une insuffisance renale, doivent faire l'objet d'etudes. La surveillance des insuffisants renaux par un pharmacien a permis d'optimiser la posologie et de realiser des economies.

An analysis of pharmacist interventions.

In a 620-bed acute care teaching hospital, the hospital pharmacists are therapeutic specialists and have become integrated members of the health care team working on the nursing units. To determine the extent of cost avoidance and savings achieved by pharmacist monitoring of drug prescribing and administration, a six month study was undertaken in one of five pharmacy satellites. The pharmacists documented each clinical intervention on form designed for this investigation. Cost reductions or cost avoidance accrued due to the pharmacists' clinical interventions, such as monitoring overuse of drugs, unnecessarily prolonged hospitalization, correction of medication errors, and reassessment of prescriptions. This study suggests that pharmacists clinical expertise in drug use can benefit patients, physicians, nurses, and the hospital administrators who are confronted with ever increasing costs.

Pharmacist monitoring of the timing of preoperative antibiotic administration

Pharmacist monitoring of the timing of preoperative antibiotic administration

Drug-use evaluation programs for psychotropic medications

Drug-use evaluation (DUE) programs for psychotropic medications at a state-operated mental health center are described. DUE programs were developed at Western Missouri Mental Health Center to monitor prescribing of medications in the hospital and ambulatory-care settings. DUE criteria were developed for all major groups of psychotropic medications: antipsychotics, antidepressants, antianxiety and hypnotic agents, lithium, and antiparkinsonian drugs. The criteria appear on special forms developed for the programs; pharmacists use these forms to evaluate every medication order for inpatients and every 50th medication order for ambulatory-care patients. Physicians are alerted to noncompliant prescribing practices by memorandum, oral consultation, or both. In 3204 inpatient DUEs conducted from July 1986 to December 1988, orders for antiparkinsonian drugs showed the poorest compliance with DUE criteria. In both the hospital and ambulatory-care settings, antiparkinsonian agents required the most follow-up. The overall compliance rate for inpatient DUEs was 84%; for ambulatory-care DUEs, the compliance rate was 64%. As a result of the ambulatory-care DUE program, basic laboratory studies and dyskinesia rating scales are being ordered on a more timely basis. These DUE programs have increased pharmacist monitoring of patient care and improved documentation of medication use.

Pharmacist Control Over OTC Merchandising

This study was conducted to determine whether independent pharmacists differ significantly from chain pharmacists in the control they exert over the selection, purchase, placement, and promotion of over-the-counter (OTC) products. The sample consisted of randomly selected community pharmacists in Maryland. The products selected for study were products that had been switched recently from legend to OTC status, controversial products, or products for which pharmacist counseling or monitoring was appropriate. Results indicated that chain pharmacists exerted significantly less control over the product selection and merchandising decisions than independent pharmacists. The study also found that for two of the product categories-controversial products and recent legend-to-OTC switches-merchandising control was evident when pharmacists made the product selection and placement decisions. In the third category-pharmacist-supervised OTCs-no significant difference was found between pharmacies merchandised by pharmac...

Indicators for the selection of ambulatory patients who warrant pharmacist monitoring

The development of indicators to identify ambulatory patients who might benefit from pharmacist monitoring is described. With the assistance of an eight-member panel of ambulatory-care pharmacists, six prognostic indicators were identified: (1) five or more medications in present drug regimen, (2) 12 or more medication doses per day, (3) medication regimen changed four or more times during the past 12 months, (4) more than three concurrent disease states present, (5) history of noncompliance, and (6) presence of drugs that require therapeutic drug monitoring. The charts of patients who had visited the internal medicine, general surgery, pediatric, and obstetric/gynecology clinics during five randomly selected weeks in 1985 and 1986 were reviewed to determine the presence or absence of the six prognostic indicators and their adverse outcomes. Evidence of drug-therapy-related adverse outcomes was present in 79 (33.1%) of 239 charts. Charts of patients with a documented history of noncompliance were most likely to show evidence of an adverse outcome. The likelihood that a patient chart would show evidence of an adverse outcome increased as the number of prognostic indicators present increased. The presence of individual or multiple prognostic indicators in the charts of ambulatory-care patients should enable pharmacists to identify patients at greatest risk of experiencing drug-therapy-related adverse outcomes.

Pharmacist Control Over OTC Merchandising

This study was conducted to determine whether independent pharmacists differ significantly from chain pharmacists in the control they exert over the selection, purchase, placement, and promotion of over-the-counter (OTC) products. The sample consisted of randomly selected community pharmacists in Maryland. The products selected for study were products that had been switched recently from legend to OTC status, controversial products, or products for which pharmacist counseling or monitoring was appropriate. Results indicated that chain pharmacists exerted significantly less control over the product selection and merchandising decisions than independent pharmacists. The study also found that for two of the product categories-controversial products and recent legend-to-OTC switches-merchandising control was evident when pharmacists made the product selection and placement decisions. In the third category-pharmacist-supervised OTCs-no significant difference was found between pharmacies merchandised by pharmacists and those merchandised by nonpharmacists.

Economic Consequences of Two Drug-use Control Systems in a Teaching Hospital

Length of stay (LOS), total cost per admission (TCA), and pharmacy cost per admission (DCA) were determined for two drug-use control systems in a 1058-bed university hospital; a centralized unit dose drug distribution system served as a control. The two study systems were (1) pharmacist monitoring of drug therapy in the patient-care area and (2) centralized pharmacist monitoring of computerized patient profiles. LOS data were collected retrospectively for 659 patients admitted during a seven-month control interval. LOS, TCA, and DCA data were collected prospectively for 496 patients admitted during a five-month experimental interval. Each study system was assigned to one of three teams making rounds among intact patient groups. LOS differences were compared between intervals and by month. After corrections were made for differences in patient mix, the drug-use control system in which pharmacists were assigned to the patient-care area yielded a 1.5-day-shorter average LOS, $1293 lower average TCA (p less than 0.05), and $155 lower average DCA than under the unit dose system. The drug-use control system in which pharmacists were assigned to monitor patients' drug therapy from a central location was associated with a 0.13-day-shorter average LOS, $235 lower average TCA, and $55.13 lower average DCA than under the unit dose system. No systematic differences between teams, other than drug-use control system, appeared to explain the differences in LOS, TCA, and DCA. A drug-use control system based in a patient-care area, overseen by clinically experienced pharmacists, may result in shorter LOSs and lower total costs than centralized systems for general-medical inpatients of teaching hospitals.

Controlling admixture waste through pharmacist monitoring

Controlling admixture waste through pharmacist monitoring

Standardized versus pharmacist-monitored individualized parenteral nutrition in low-birth-weight infants

The clinical contribution and cost effectiveness of pharmacist involvement in peripheral-vein total parenteral nutrition (TPN) in a neonatal intensive-care unit was studied. Fourteen neonates who received a standardized TPN solution without pharmacist monitoring (Group 1) were compared with 14 neonates who received an individualized TPN solution with pharmacist monitoring (Group 2). Infants were excluded from the study if they received oral feeding, or TPN for less than five days, or were fluid-restricted. No significant difference in mean gestational age, birth weight, gestational size, age at initiation of therapy, duration of therapy, or daily amount of fluid administered was found between the two groups. The mean weight gain in Group 1 (4.9 g/day) was significantly less than in Group 2 (11.8 g/day) (p less than 0.02). The amount of protein provided to Group 2 (2.2 g/kg/day) was significantly greater than to Group 1 (1.9 g/kg/day) (p less than 0.01). The number of calories provided per day was greater for Group 2 (63 kcal/kg/day) than for Group 1 (53 kcal/kg/day) (p less than 0.001). When only those infants who received lipids were analyzed, Group 2 received significantly more lipid (2.0 g/kg/day) than group 1 (1.5 g/kg/day) (p less than 0.001). The mean daily cost was greater for Group 2; however, when cost was related to efficacy, Group-2 cost per gram of weight gain was lower than Group-1 cost. Pharmacist monitoring of an individualized program of TPN in neonates provided a greater mean daily weight gain, allowed a greater amount of nutrients to be provided, and was cost effective compared with the use of a standardized solution without pharmacist monitoring.

Effect of pharmacist intervention on the use of serum drug assays

The results of an investigation to (1) evaluate the use of serum drug assays (SDAs), (2) study the influence of clinical pharmacist monitoring and educational programs on SDA use, and (3) perform drug-related patient-care evaluations for the medical audit committee are reported. The components of the five-month study were a retrospective audit, education of physicians prescribing SDAs, and a concurrent reaudit. The four SDAs audited were digoxin, theophylline, gentamicin, and phenytoin. Criteria for appropriate use were defined by the audit committee and a clinical pharmacist. The criteria specified the indication for each drug, performance data, and dosage adjustments with SDA results. The clinical pharmacist presented two housestaff conferences on the appropriate use of SDAs and distributed educational materials to the attending physicians. An SDA report form was completed each time an SDA was ordered, and, whenever possible, the pharmacist met with the prescribing physician. Appropriate overall use of SDAs increased significantly (p less than 0.05). A significant improvement (p less than 0.05) was noted for each of the criteria. An estimated $2500 in patient charges was saved during the study; the cost of the clinical pharmacist's time was approximately $260. The authors concluded that clinical pharmacists, in conjunction with patient-care evaluations, can provide a cost-effective service in improving therapeutic patient monitoring based on SDA results.

Concurrent pharmacist monitoring of gentamicin therapy

The results of concurrent monitoring of gentamicin therapy by a clinical pharmacist are reported. All patients in a 332-bed teaching hospital who were started on gentamicin therapy during a 72-day period were monitored. Predetermined criteria concerning maximum daily gentamicin dose based on serum creatinine and acceptable precautions for avoiding toxicity (i.e., serum creatinine, gentamicin serum level determinations) were used. Deviations from these criteria resulted in contact with the patient's physician, and specific recommendations were made by the pharmacist at that time. During this period, 120 courses of gentamicin therapy were monitored in 101 patients. Major criteria deviations were found in 15 (12.5%) courses, resulting in the contact of 10 physicians. Physicians responded to the pharmacists' recommendations in 9 (60%) of the 15 courses. It is concluded that a clinical pharmacist can interact effectively with physicians in monitoring drug therapy in the hospital.

Pharmacist monitoring of parenteral nutrition: Clinical and cost effectiveness

The effect of pharmacist involvement in total parenteral nutrient (TPN) therapy on patient outcome and cost of therapy was studied. Data from 26 patients who received standard TPN solutions without pharmacist monitoring (Group 1) were compared with those from 26 patients whose TPN therapy was individualized (by use of a minicomputer) and monitored by a pharmacist (Group 2). Six patients from each group who were 35 days of age or younger and who received TPN as the only caloric source for 8 to 20 days were compared for clinical response. Mean duration of TPN therapy increased form 12.3 +/- 9 days for Group 1 to 14.8 +/- 12 days for Group 2, and the TPN use rate for Group 2 was 31% above that for group 1. The mean daily charge for TPN was greater for Group 1 ($72.00) than for Group 2 ($50.18). The pharmacy's mean cost per course of TPN for Group 2 was $44.10 less than that for Group 1. The mean weight gain in Group 1 was significantly less (4 g/day) than that in Group 2 (17 g/day) (p less than 0.05) (for the six patients per group compared). Pharmacist monitoring of TPN reduced the pharmacy's costs and patient charges for TPN and improved the patients' clinical responses to TPN.

Primary care by a pharmacist in an outpatient clinic

Primary care by a pharmacist in an outpatient clinic of the Indian Health Service is described. Primary care responsibilities of the pharmacist included the diagnosis and treatment of certain acute illnesses and the management of selected chronic disease patients. Protocols were written by the pharmacist and physician to cover 31 acute illnesses and seven chronic conditions. The pharmacist was also trained to perform many routine laboratory tests. Further, the pharmacist provided patient consultation as to the use, storage, benefits and expected side effects of prescribed medications. Pharmacy visits accounted for nearly one-third of the clinic visits in 1975. Diagnosis and treatment of 10 common acute illnesses made up more than 40% of the pharmacy visits; another 40% of these visits were for pharmacist monitoring of chronic conditions.