Hospital Pharmacy in Canada2005-2006

Hey Kid … what do you do now ?

Jean-François BussièresB Pharm MSc MBA FCSHP

Chef, département de pharmacie et unité de recherche en pratique pharmaceutique

Professeur agrégé de cliniqueFaculté de pharmacie, Université de Montréal

Membre du comité de rédactionRapport canadien sur la pharmacie hospitalière

Match plan

• Objective : provide participants with an overview of the alignment of hospital pharmacy practice (e.g. clinical pharmacy) with the evidence– What do we Know ?– What do we Ignore ?– What should we Do ?

Who are we ?

• Response rate = 74 %• Teaching institutions = 26 %

Johnson N et al. Hospital Pharmacy in Canada 2005-6

Who are we ?

• Please consider absolute numbers … but prefer ratios when available

• Always understand what’s behind the numbers

Johnson N et al. Hospital Pharmacy in Canada 2005-6

Clinical practice models

• Clinical pharmacy has celebrated its 40th anniversary in 2006

• There are many models and philosophy• Traditional clinical services

– range of services based on a medication or a particular pharmaceutical function designed to optimize a given result for the patient; for example pharmacokinetic services, total parenteral nutrition (TPN) monitoring services and so on.

• Pharmaceutical care– organized delivery of pharmacotherapeutic services to achieve well-

defined therapeutic results. In particular, it means designing, applying and managing a therapeutic care plan of monitoring, prevention and solution of pharmacotherapeutic problems, potential or real.

• Interdisciplinary pharmacy practice• Total pharmacy practice

Clinical practice models• Traditional (89 %) and pharmaceutical care (82 %) are

largely implemented• Pharmacy departments use both models and an

important % or beds are still non covered

Johnson N et al. Hospital Pharmacy in Canada 2005-6

Clinical practice models

• Pharmaceutical care AND absence of clinical services have progressed over the last 10 year-period

Practice models

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100%

1996-1997 1997-1998 1999-2000 2001-2002 2005-2006

Fiscal years

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Pharmaceutical care model

Traditional clinical services

No clinical services

Clinical practice models

• The proportion of beds covered by PC has increased while the proportion of beds uncovered has decreased

Bed coverage per practice models

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1996-1997 1997-1998 1999-2000 2001-2002 2005-2006

Fiscal years

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% of beds covered - PC

% of beds covered - TCS

% of beds Uncovered - None

Clinical practice models

But we ignore … – If this distinction between models is still

useful and reliable to report ?– If one model is superior to the other in all

cases or some cases ?– What criteria should influence the

implementation of one model or the other ? What is the best model mix ?

– What will be the impact of the entry-level Pharm. D. on practice models

Clinical practice models

So we have to …• Ensure that each pharmacy department

has a reproductible framework for clinical pharmacy services

• Ensure a better coherence between academia, hospital and community pharmacy practice

• Document and publish successful practices from role model

A new entry-level Pharm. D.

Transversals• Professionnalism• Communication• Team work and interdisciplinarity• Scientifical reasoning and critical thinking• Autonomy in learning• LeadershipSpecifics• Pharmaceutical care• Service to the community• Pharmacy management and operations

A new entry-level Pharm. D.

A new entry-level Pharm. D.

• Module A – Drugs and the human

• Module B – Drugs and society

• Module C – Labs

• Module D – Integration activities

• Module E – practical training/internship

• Module F – optional courses

Staffing• There are different ratios that can be used to

compare pharmacy staffing to others e.g. doses dispensed/y, case-mix index-ajusted patient-days, admission, occupied beds etc.

Gupta SR et coll. AJHP 2007; 64: 937-44.

Staffing

• 15 FTE pharmacists/ 100 occupied beds

• 7 times more integrated pharmacists than clinical pharmacists/100 occupied beds

Pedersen CA et al. AJHP 2007; 64: 507-20.

Staffing• 19,1 FTE/100 occupied bed (estimated

occ. Rate – 85 %) vs 14 up to 20 FTE/100 occupied bed in USA

Johnson N et al. Hospital Pharmacy in Canada 2005-6

Staffing

Johnson N et al. Hospital Pharmacy in Canada 2005-6

Staffing

But we ignore what …– Is the optimal staffing in terms of FTE to fulfill

adequately patient needs– Is the optimal ratio pharmacists / non

pharmacists – Should be the future role of pharmacy

technicians for non dispensing activities– Is the impact of having a non-pharmacist as a

head of pharmacy department

Staffing

So we have to …– Collect indicators to be able to calculate ratio

(# dose dispensed, # patient-days adjusted for case-mix …)

– Agree upon key ratio to be reported at least regionally for benchmarking

– Develop indicators for ambulatory/outpatient care activities

Time devoted to clinical pharmacy

• Only 24 % of respondants devote > 29 % of their time to monitoring medication therapy in US

Pedersen CA et al. AJHP 2007; 64: 507-20.

Time devoted to clinical pharmacy

• 41 % of pharmacists’ time is devoted to clinical (patient care) activities in Canada

Johnson N et al. Hospital Pharmacy in Canada 2005-6

Time devoted to clinical pharmacy

But we ignore what …– Is the optimal % of time of clinical activities for

a pharmacy department– Is the optimal % of time for clinical activities of

an individual on a daily, weekly, monthly or annual basis

– Is the optimal number of clinical specialty per individual (1, 2, more ?)

Time devoted to clinical pharmacy

We have to …

• Agree upon a simple system to capture (bill) the nature of pharmacy services provided by individual on a regular basis

• Evaluate the optimal mix (clinical/non clinical) for productivity, retenteion and impact of pharmacists

SpecializationOutpatient and inpatient pharmacy services

OUTPATIENT• Hematology-oncology – 80 %• Renal/dialysis – 63 %• Emergency – 54 %• Anticoagulation – 52 %• Infectious disease/AIDS – 40 %• Diabetes – 39 %• Transplantation – 31 %• Mental health – 27 %• Geriatrics/LTC – 26 %• Pain/ palliative care – 26 %• Asthma / allergy -16 %• General medicine – 14 %• General surgery – 14 %• Neurology – 13 %• Gynecology – obstetrics – 8 %• Rehabilitation – 7 %

INPATIENT• Geriatrics/LTD – 83 %• Adult critical care – 79 %• Hematology-oncology – 78 %• General medicine – 78 %• Pain / palliative care – 70 %• Cardiovasculair /lipid – 68 %• Mental health – 63 %• General surgery – 63 %• Pediatric /neonatal critical care – 56 %• Renal / dialysis – 51 %• Rehabiliation - 50 %• Hematology/anticoagulation – 46 %• Infectious disease/AIDS – 46 %• Transplantation – 45 %• Gynecology – obstetrics – 43 %• Diabetes – 41 %• Neurology – 40 %• Asthma-allergy – 37 %

Johnson N et al. Hospital Pharmacy in Canada 2005-6

SpecializationOutpatient pharmacy services

Johnson N et al. Hospital Pharmacy in Canada 2005-6

SpecializationInpatient pharmacy services

Johnson N et al. Hospital Pharmacy in Canada 2005-6

Effectiveness of hospital pharmacy• Litterature search and review• Different domains

– General medication review and clinical intervention monitoring– Multidisciplinary teamwork– Patient’s own drugs and self-administration schemes– Pre-admission clinics– Patient discharge services– Shared care, primary/secondary care interface and outreach services– Outpatient service– Mental Health– Intensive care units and theatres– Patient counselling and education– Aseptic services– Non-sterile manufacturing– Pain control– Medicines information– Anticoagulant services– Pharmacokinetic and therapeutic drug monitoring services– Extended hours, residency and on-call services– Strategic medicines management, formulary services and clinical audit– Education and training– Renal services– ADR and clinical risk management– Computer support services– Pharmacist prescribing– Pharmacy technicians and ATO’s– Others

Guild of healthcare pharmacists. 2001

Effectiveness of hospital pharmacy

Guild of healthcare pharmacists. 2001

• 10 099 articles• 13 reference database (Medline, Pharmline, EPIC, etc.)• Mainly UK publications• No statistical analysis• Most studies have positive results (publication biais ?)• Authors have identified 7 key concerns

Specialization

But we ignore …

• How to better prioritize a clinical specialty vs another

• The evidences about the impact of pharmacist per specialty

• What level of resources should be devoted to a specific specialty

• How to recognize specialist vs generalist

Specialization

But we have to …

• Monitor published evidences for pharmacy practice as for drug therapy

• Build business cases for clinical pharmacy with evidences, patients and professionals needs

• Recognize specialist in pharmacy

Impact of clinical pharmacy

• Clinical pharmacy can have– A positive impact on costs– A positive impact on adverse drug event,

reaction and medication error– A positive impact on lenght of stay– A positive impact on

Economic benefits

Economic benefits

Effect of pharmacists’ interventions on patient and process outcomes

Effect of pharmacists’ interventions on patient and process outcomes

• 343 articles retrieved from 1985-2003 but only 36 included• Controlled studies, inpatient, patient outcomes

– Pharmacists’ participation on medical rounds (n= 10)

– Medication reconciliation studies (n=11)

– Drug specific services (n=15)

• Global impact– ADE, ADR or ME were reduced in 7/12

– Medication adherence, knowledge and appropriateness were improved in 7/11

– Shorten lenght of stay in 9/17

– Higher use of healthcare in one study

– No studies reported worse clinical outcome

Association between pharmacists, clinical pharmacy and health care outcomes

Bond CA et al. Pharmacotherapy 2001; 21 (2): 129-41.

• Increasing # pharmacists/100 occupied beds is associated with a reduction in # deaths/hospital/year

• Increasing # clinical pharmacists/100 occupied beds is associated # deaths/1000 admissions

Association between pharmacists, clinical pharmacy and health care outcomes

Bond CA et al. Pharmacotherapy 2001; 21 (2): 129-41.

• Increasing # clinical pharmacists is associated with a reduction in LOS

Association between pharmacists, clinical pharmacy and health care outcomes

Bond CA et al. Pharmacotherapy 2006; 26 (6); 735-47

50 % des ADR/year by increasing the # clinical pharmacists/100 occupied beds from 0,9 à 5,7

Association between pharmacists, clinical pharmacy and health care outcomes

• Medication errors/occupied bed/year rate is lower – when pharmacists are decentralised (1,74)

– or centralized with ward visits (1,93)

• Vs centralized (3,15)

BEFORE

PrioritizationAdmission and discharge interviews

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Proportion of respondants (%)

1986-1987

1987-1988

1989-1990

1990-1991

1991-1992

1992-1993

1993-1994

1994-1995

1995-1996

1996-1997

1997-1998

1999-2000

2001-2002

Fiscal years

Clinical activities w ith patients

Admission interviews

Discharge interviews

Prioritization - Rounds and consultation with physicians and kardex rounds with nurses

Clinical activities w ith physicians and nurses

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1986-1987 1987-1988 1989-1990 1990-1991 1991-1992 1992-1993 1993-1994 1994-1995 1995-1996 1996-1997 1997-1998 1999-2000 2001-2002

Fiscal years

Rounds with physicians

Consultation with physicians

Kardex rounds with nurses

Prioritization Pharmacokinetic dosings

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Proportion of respondants

off ering PKD

1986-

1987

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1988

1989-

1990

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1991

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1992

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1993

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1994

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Fiscal years

Growth of PK dosing

Pharmacokinetic dosing nd

AFTER

Average level of service and ranking priority

Johnson N et al. Hospital Pharmacy in Canada 2005-6

Average level of service and ranking priority

Johnson N et al. Hospital Pharmacy in Canada 2005-6

Prescribing

Evaluation

Johnson N et al. Hospital Pharmacy in Canada 2005-6

Prioritization

But we ignore …

• How to prioritize amongst all clinical pharmacy activities

• How to better delegate or collaborate with other professionals without losing the essence of pharmacy practice

• How to document and evaluate theses activites

2015 Vision

So what’s next ?

• Find, read, understand and use evidences• Document, benchmark, evaluate and update

models, specialty areas, hierarchy of activities• Meet, discuss, move towards consensus about

pharmacist role to develop an evidence based practice model

• Question, research, answer, publish and transfer the knowledge within and outside the profession