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October 18, 2013

State Society Perseveres in Effort to Advance Pharmacy Profession

Filed under: Ambulatory Care,Current Issue,Feature Stories,Managers — Kathy Biesecker @ 5:11 pm
New legislation passed by the California Senate now confers "health care provider status" on pharmacists.

New legislation passed by the California Senate confers “health care provider status” on pharmacists in the state.

THE ROAD TO VICTORY for California Senate bill 493 (PDF) was neither straight nor smooth.

“This was a major fight,” said Dawn Benton, chief executive officer of the California Society of Health-System Pharmacists (CSHP).

Meetings between CSHP staff and state legislators or their staff occurred practically every day throughout the legislative process, she said.

But on September 12, after several Senate and Assembly hearings, votes, and amendments over the course of seven months, the bill emerged from the California State Legislature.

And on October 1, Governor Edmund G. Brown Jr. added his signature.

Come January 1, the California government will recognize pharmacists as “health care providers who have the authority to provide health care services.”

Furthermore, those pharmacists whom the state board of pharmacy recognizes as advanced practice pharmacists may provide certain additional services.


Jonathan Nelson, government affairs manager, California Society of Health-System Pharmacists


CSHP and its legislative partner, the California Pharmacists Association, worked in earnest to resolve conflicts with “the opposition,” said Jonathan Nelson, government affairs manager for the health-system pharmacists group.

The pharmacist groups succeeded in part, he said, by explaining some of the bill’s provisions in terms clearer than in earlier versions.

Even the California Academy of Family Physicians and the California Medical Association (CMA) had removed their opposition by the time the bill headed to the Assembly floor.

Hundreds of CSHP members wrote letters to their legislators, Nelson said. Many members in addition helped with the financial part of the legislative effort and met with their legislators to explain the contributions of pharmacists on the health care team.

“Their actions really helped pave the way to victory,” he said.

Collaboration, Not Independence

Something the pharmacists purposely did not do was important as well, said CSHP President Steven Gray.

“We did not claim that we were independent in the sense that we diagnose,” Gray said. “Pharmacists are not trained to diagnose. So we didn’t use the d word in anything.”

Similarly, the pharmacists did not claim to provide primary care, he said.

“In the nonpharmacist world,” Gray explained, “primary care means that you’re the person that sees the patient and diagnoses.  We may see a patient first when they walk in the pharmacy, but we refer them to a physician or other diagnostic profession. And then, once they determine what the problem is, we’re there to assist with the management of the drug therapy.”

More information on the law is available in the nine-page “What Does SB 493 Mean to Me?” fact sheet (PDF) prepared by the two pharmacist groups.

Dawn Benton, executive vice president and CEO of the California Society of Health-System Pharmacists (CSHP)

Dawn Benton, CSHP executive vice president and CEO


Senator Ed Hernandez, who introduced the legislation, had contacted the pharmacist groups last year and relied on them for the bill’s language, Benton said.

His legislation to establish independent practice for nurse practitioners and permit optometrists to diagnose conditions and disorders of the eye, however, are still with Assembly committees.

Benton said the pharmacist groups ensured that their legislation stated the need for communication and collaboration with patients’ physicians.

“In our negotiations with CMA, the physicians were very concerned that the pharmacists not be acting independently,” she said.

The State’s Need

Nelson said the California pharmacist groups looked at New Mexico’s and North Carolina’s legislation on advanced practice pharmacists “as a starting point, as an inspiration.”

But both states passed their legislation more than 10 years ago, which meant the California pharmacists could not rely solely on the language in those bills, he said.

After President Obama signed the Patient Protection and Affordable Care Act in 2010, California’s government started planning to ease the eligibility requirements for the Medicaid program and implement a health insurance exchange.

“We needed something in California, we felt, to handle the increase in demand for health care both in terms of quantity and complexity,” Gray said. “And that was the main reason that we felt that it was imperative to get this bill through and allow pharmacists to be a part of the solution and apply the full breadth of their training and experience.”

Commercial insurers’ interest in having pharmacists provide collaborative drug therapy management in accountable care organizations was also taken into consideration, he said.

“They were starting to run into problems,” Gray said. “They couldn’t find enough of the collaborative drug therapy management pharmacists.”

A 1994 California law allows certain pharmacists to provide collaborative drug therapy management in health care facilities. Those pharmacists have completed a clinical residency training program or had showed clinical experience in providing direct patient care.

Gray said the number of pharmacists wanting to complete such a residency program has outpaced the openings.

CSHP’s members, he said, saw the urgent need for “an alternative pathway.”

The new law, in creating the designation “advanced practice pharmacist” and further expanding the scope of pharmacists’ practice, adds certification in a relevant practice area as a pathway.

Blue Shield of California, which has accountable care organizations in several areas of the state, supported the bill.

Not Done

Benton said CSHP started receiving congratulations from people around the country once word spread about the governor approving the bill.

“We’ve got a lot of work ahead of us, and we’re already getting started,” she said.

The state boards of pharmacy and medicine, for example, must agree on the standardized procedures and protocols for pharmacists to furnish prescription nicotine-replacement products. And, as another example, the state board of pharmacy must develop a process for accepting applications for recognition as an advanced practice pharmacist.

Benton said CSHP will participate at every opportunity.

—By Cheryl A. Thompson

Editor’s Note: This article, which was originally published on, is reprinted with permission.

Antibiotic Stewardship Team Improves Drug Use, Reduces Costs

From left, Eugene Varoz, clinical pharmacist, consults with Peggy Reap, R.N., and Madhur ??, M.D.

From left, Eugene Varoz, clinical pharmacist, consults with Peggy Reap, R.N., and Madhuri Segireddy, M.D., ID specialist at Chandler Regional Medical Center.

AN AGGRESSIVE ANTIMICROBIAL stewardship program established jointly by Mercy Gilbert and Chandler Regional Medical Centers led to a significant decline in unnecessary antibiotic therapy and a 25 percent reduction in costs for frequently used and expensive antibiotics. Gilbert and Chandler are two Phoenix, Ariz., hospitals in the Dignity Health network.

“Our antibiotic costs were increasing rapidly and had become one of the top drug expenditures in the pharmacy,” said Bina Patel, Pharm.D., pharmacy manager at Chandler Regional, who Patel co-led the cross-site team with Jennifer Ng, Pharm.D., former clinical pharmacy supervisor at Mercy Gilbert.

Dr. Patel noted that just five antibiotics were responsible for 60 to 70 percent of antibiotic costs at the two facilities. “We also found that these broad-spectrum antibiotics were often prescribed inappropriately,” she said.

Neither hospital’s pharmacy regularly reviewed antibiotic order patterns, resulting in inconsistent prescribing practices and antibiotic overuse.

The hospitals formed a multidisciplinary team tasked with creating an antimicrobial stewardship program that could be incorporated into routine medication management. In addition to Drs. Patel and Ng, the team included an infectious disease pharmacist, an infection preventionist, a microbiologist, an infectious disease physician, an emergency medicine physician, and a hospitalist.

Identifying Underlying Causes of the Problem

Using a form of Lean methodology called Transformational Care (TC), the team set out to identify the root causes of the problem and create quick and efficient solutions. TC and Lean methodology help to streamline and simplify systems and eliminate waste. Each team member underwent 12 weeks of TC training.

The team discovered that pharmacists were playing only a limited role in managing infectious disease therapies. Standardized diagnostic order sets, pharmacy reviews, and interventions also were lacking.

In the face of these challenges, the team developed criteria for using broad-spectrum, high-cost antibiotics and formulated evidence-based guidelines for antibiotic use. They also created an antibiogram displaying the sensitivities of various isolated bacterial strains to different antibiotics.

This information was then published in pocket guides and distributed to prescribers. Standardized adult antibiotic order sets based on frequent diagnoses (e.g., pneumonia, cellulitis, and urinary tract infections) were also developed to improve the accuracy of antibiotic selection.

Dr. Bina Patel, Pharm.D.

Dr. Bina Patel, Pharm.D.

“The forms are targeted primarily at hospitalists and emergency department physicians so they don’t have to spend time thinking about what they need to do empirically,” explained Dr. Patel. “The physicians can use the form to simply check off the correct antibiotic based on the diagnosis and send it to the pharmacy. Because the drug choice was selected from the approved form, the order doesn’t need to be reviewed.”

For inpatients, an infectious disease pharmacist reviews orders for the top five targeted antibiotics to ensure that they are well matched to an empiric diagnosis. When culture results become available, the pharmacist rechecks to determine if the therapy is appropriate. If a change is needed, the pharmacist calls the prescribing physician to recommend a more suitable antibiotic, decrease the dose, switch from IV administration to an oral form, or discontinue therapy entirely.

Physician Education and Metrics

The program has been a great success. During its first year, pharmacists conducted 1,966 interventions at both hospitals, 93 percent of which were accepted by physicians.

“We also conducted physician education to increase awareness of antimicrobial stewardship and what it means to the quality of patient care,” said Dr. Patel. “That helped to win acceptance.”

To gauge the impact of the initiative, the team tracked, among other metrics, the average daily defined doses (DDD) of the five target antibiotics, the number of patients prescribed the target drugs, the length of therapy, and drug costs.

The results have been impressive. During the program’s first year, the average DDD decreased for all of the top five targeted antibiotics—in one case by more than 70 percent (see box). The cost per inpatient day for the five drugs decreased 26.4 percent, and the total antibiotic cost per inpatient day dropped 14.2 percent. The number of patients prescribed the target antibiotics for more than five days also declined.

After the first year, the changes leveled out, which Dr. Patel expected. Now, near the end of the program’s third year, the challenge is to hold onto the gains and widen the net.

“We achieved a significant reduction from baseline in both drug usage and costs. Now we need to maintain that progress,” she said. “We’ve also expanded the program to look at other antibiotics.”

Recruiting Champions

The initiative has raised the visibility of clinical pharmacists, according to Dr. Ng, now a clinical pharmacist at Banner Baywood Medical Center in Mesa, Ariz.

Jennifer Ng, Pharm.D.

Jennifer Ng, Pharm.D.

“Initially, some of the physicians were not used to pharmacist interventions, at least with antibiotics,” she said. “Later, their responses became far more positive, and they said they appreciated and even expected the calls. Resistance really dissipated once the doctors understood what we were trying to accomplish.”

Dr. Ng emphasized the importance of a multidisciplinary team and having a physician advocate on the team.

“Having at least one physician champion goes a long way,” she said, noting the support of an infectious disease doctor on their team. “It shows the rest of the hospital that the program is not just the pharmacy out there on its own, and it drives home the point that there’s a bigger goal in terms of patient care.”

Administrative support, another factor that was crucial to the program, was present from the start.

“The pharmacy and the infection control physicians led the way,” said Peter Menor, vice president of operations at Chandler Regional and the executive sponsor for the initiative. “My role was to give them the resources to get the job done. The program spread very quickly. Before we knew it, the entire medical staff was involved. It’s been very well received and it’s had an enormous impact on patient care.”

–By Steve Frandzel


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