ASHP InterSections ASHP InterSections

August 15, 2016

In an Anticoagulation Clinic, Unrelated Interventions Abound

Melanie Boros, Pharm.D., BCPS, meets with a patient at Cleveland Clinic Akron General's outpatient anticoagulation clinic.

Melanie Boros, Pharm.D., BCPS, meets with a patient at Cleveland Clinic Akron General’s outpatient anticoagulation clinic.

IT’S WELL KNOWN that when pharmacists guide anticoagulation treatment, patient outcomes are better. International normalized ratio (INR) levels are within the target range more of the timei and hemorrhage rates are lowerii, compared to the usual care.

But what about the care pharmacists provide in anticoagulation clinics that is not directly related to the primary purpose of the visit?

A new study published in AJHP found that pharmacists offer significant additional care outside the purview of anticoagulation by helping patients avoid adverse events and receive timely treatment for other health concerns, and by improving their continuity of careiii.

Med Rec Reveals Important Picture of Patient Health

Michael Hicho, Pharm.D., BCPS

Michael Hicho, Pharm.D., BCPS

“Pharmacists, whether they’re in the anticoagulation clinic or in any other setting, can make a significant positive impact on patients’ care if they take advantage of each interaction they have with a patient,” said primary author Michael Hicho, Pharm.D., BCPS, who was a PGY1 pharmacy practice resident at Akron General Medical Center, Akron, Ohio, at the time of the study. Dr. Hicho is currently Inpatient Clinical Manager, Pharmacy Service, at Louis Stokes Cleveland VA Medical Center, Cleveland.

“As our findings show, these interactions may not necessarily always involve starting, stopping, or adjusting a medication but can, for example, include collaboration with other healthcare providers to ensure that patients are receiving appropriate care,” he said.

Dr. Hicho drew these conclusions from a retrospective analysis of records from 5,846 pharmacist encounters with 268 patients treated at the Akron General Medical Center’s pharmacist-managed ambulatory anticoagulation clinic between January 2012 and November 2013. The clinic served patients referred by 30 physicians during the study period.

Dr. Hicho’s team classified interventions not directly related to anticoagulation into six major categories (see TABLE below) and 33 subcategories. They found that pharmacists conducted a striking 2,222 interventions not directly related to patients’ primary reasons for visiting the anticoagulation clinic. Nearly 75% of patients received four or more unrelated interventions and almost 14% received 10 or more of these interventions.

Medication reconciliation was the most common intervention not directly related to anticoagulation. During those interactions, pharmacists identified 1,591 medication list discrepancies, including inaccuracies in the medication list for 89% of these instances.

They also found 107 instances in which a patient was taking his or her medication incorrectly and an additional 74 cases in which there was a possibility a patient may have been taking his or her medication incorrectly.

The Continuity of Care Equation

According to Dr. Hicho, pharmacists helped ensure continuity of care by assessing patients’ overall health, sending physicians medical information they collected, recommending primary care physician follow-up, and, in some cases, calling a physician for an immediate onsite visit or urging patients to visit the emergency department.

Amy Rybarczyk, Pharm.D., BCPS

Amy Rybarczyk, Pharm.D., BCPS

Measuring the clinical and financial value of interventions like these is difficult, said co-author Amy Rybarczyk, Pharm.D., BCPS, Pharmacotherapy Specialist in Internal Medicine, Cleveland Clinic Akron General. “At the moment, there is no standardized method for quantifying pharmacist interventions,” said Dr. Rybarczyk, who was Dr. Hicho’s research advisor at the time of the study. “It’s hard to measure the value of ensuring that a patient gets an antibiotic for a diabetic foot infection that is detected by a pharmacist, for example. A tool like that would be beneficial for our profession to have.”

Collaborative Practice Agreement Buoyed by Findings

The team’s results were so impressive that they were included in a letter to the Ohio Legislature in support of House Bill 188, which called for an expansion of pharmacists’ services as part of collaborative practice agreements. The legislation passed in December 2015.

“We believe the comprehensive care provided to patients in our disease state management clinic helped in this effort to expand pharmacists’ clinical services,” explained Dr. Rybarczyk.

“We believe the comprehensive care provided to patients in our disease state management clinic helped in this effort to expand pharmacists’ clinical services.” — Amy Rybarczyk, Pharm.D., BCPS

Co-author Melanie Boros, Pharm.D., BCPS, Pharmacotherapy Specialist in Internal Medicine at Cleveland Clinic Akron General and Dr. Hicho’s research advisor at the time of study, suggested that one of the important takeaway messages is the trust that patients place in their pharmacists. “When we see a patient with a therapeutic INR, and there are no changes that need to be made to his or her anticoagulation regimen, we can still make a significant impact by simply clarifying what their dose of insulin should be or teaching them about appropriate use of nonprescription medicines, for example,” she said, adding that pharmacists are well-positioned to answer patients’ questions and proactively identify other health issues.

“Like our entire department, pharmacists in the clinic have always made it a priority to care for the whole patient,” she emphasized.

–By David Wild

i J Throm Thrombolysis 2011; 32:426-430
ii Pharmacotherapy 195; 15:732-739
iii AJHP Residents Issue 2016; 73 (Supp 3):S80-87


April 6, 2016

International Pharmacy Residency a Challenging, Inspiring Experience

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Ishmael Qawiy, Pharm.D., BCACP

Editor’s Note: Author Ishmael Qawiy, Pharm.D., BCACP, is a public health resident with Bristol-Myers Squibb Foundation and Rutgers University.

ONE OF THE MOST EXCITING OPPORTUNITIES available to practitioners today is the chance to be a part of the evolution of pharmacists’ patient care roles in other countries.

I was lucky enough recently to do an international Bristol-Myers Squibb Foundation & Rutgers University public health residency.

I wanted to improve public health and explore how economic and cultural factors impact health outcomes. Community-centered pharmacy, in particular, appealed to me because of its reliance on a comprehensive approach to tackling healthcare disparities.

Beginning in July 2015, I worked in sub-Saharan Africa for six months as part of the foundation’s Secure the Future initiative. This cross-cultural program is an immersive experience in which participants address health inequities by working with indigenous people and their healthcare systems.

A Professional Shift

I arrived in Johannesburg, South Africa, excited and optimistic about making my mark in community healthcare. After being trained on the position’s scope of work, I traveled to Ethiopia, Swaziland, and Lesotho to work with grantees who are trying to reduce the incidence of cancer in women and lower the transmission of HIV.

This residency posed quite a professional shift for me, as I had previously been more comfortable doing medication management and health education. But the work was particularly exciting given the new focus on chronic disease management generally, and oncology in particular, that is currently taking place in Africa.

Dr. Qawiy poses with nurse Birhanu Moges.

Dr. Qawiy poses with nurse Birhanu Moges.

I was lucky enough to be able to work directly with the leaders of several community-based health organizations, including the African Medical and Relief Foundation (AMREF) and the Mathiwos Wondu-Ye Ethiopian Cancer Society (MWECS). These groups are on the front lines of providing care to underserved populations throughout Ethiopia.

In Ethiopia, I developed educational health materials for patients that were translated into the local language and distributed at community mobilization events. During my residency, I also created medication safety protocols and medication-handling procedures, and I developed an electronic patient database to collect and streamline reporting and improve operational efficiency.

The Reality of Healthcare in Developing Nations

During my time in Africa, I learned that it’s important to be realistic about the kinds of care you can provide when working in a developing nation with limited resources. For example, I found that standards of pharmacy practice vary from country to country. I also witnessed the fact that clinical and regulatory guidelines developed in the U.S. or in Europe weren’t well-suited for a low- or middle-income country with limited numbers of specialists and patient access to resources.

In Lesotho, for example, pharmacy technicians and nurses have the ability to dispense medications without the supervision of a pharmacist. This may raise some red flags in wealthier countries, but in low-resourced communities, building healthcare capacity by educating and training available personnel is often the most viable option. In many sub-Saharan countries, access to drugs — particularly, chemotherapy agents and pain medicines — is limited. Clearly, this negatively impacts patients’ quality of care and survivorship.

11809902_433888716818578_1803379262_nAs a public health resident, I worked on a number of different projects. For instance, I gave presentations to medical staff and hospital administrators on drug interactions and developed a framework for a drug and therapeutics committee.

I also helped create a protocol used to assess baseline awareness of cancer and met with officials with the local Ministries of Health to discuss their goals for combatting HIV and other communicable diseases.

The work was so inspiring because it made me challenge my own biases and begin to look at the world through a more culturally sensitive lens.

The Vital Role of Pharmacists

It’s important to know that if you choose to do a public health residency such as this one, it can be both professionally gratifying and emotionally taxing. During my time in Africa, I saw that health disparities can be systemic and embedded deeply in a society’s very fabric due to failed health policies, poor governance, or both. Creating equity in healthcare requires contributions from every part of society, including policymakers, healthcare providers, and the community.

I was fortunate during my residency to meet people from different walks of life and enjoy the local culture. I also found that pharmacists can contribute in significant ways to ensuring that the disadvantaged receive appropriate healthcare. Now that I’m back in the United States, I look forward to using this life-changing residency experience to explore the difference I can make in the lives of my patients.

–By Ishmael Qawiy, Pharm.D., BCACP

March 1, 2008

Pharmacists Learn Ins & Outs of Creating New ED Position

            Tanya Claiborne, Pharm.D., had just been hired as the first emergency department (ED) pharmacist at Sentara Healthcare System in Tidewater, Va., when she discovered a new ASHP program to help her navigate the challenges of her new position.
            The six-month certificate patient-care impact program—“Introducing an Emergency Pharmacist into Your Institution”—brought together 20 pharmacists under the mentorship of three pharmacists and one physician in emergency medicine.
            “It was a wonderful coincidence,” Claiborne said, of the inau­gural program that launched at ASHP’s 2007 Summer Meeting in San Francisco and concluded at the Midyear Clinical Meeting in Las Vegas. “This is a new position, so it was great to have a program where you can learn what does work and what doesn’t.”

Monitoring Performance and Quality
            Participants focused on safe medication use in the intense, pressure-filled environment of the ED, including how to moni­tor pharmacists’ performance and conduct quality assurance. They learned how to develop a pharmacist position in emergency medicine, from devising a job description to obtaining support from hospital leaders. While some of the participants hadn’t worked in EDs prior to starting the program, all of them were working in EDs upon completing it.
            Participants, who hailed from as far away as Dublin, Ireland, completed projects detailing how they would successfully implement pharmacy services in the EDs within their own organizations. They also described the duties of the pharmacist in emergency medicine, which included verifying medication orders, assisting with trauma victims, providing drug information to other health profes­sionals, and performing medica­tion reconciliation. After months of emailing their mentors and meeting in groups via teleconference, the participants displayed their projects on posters viewed by thousands of Midyear attendees.
            Participants said their projects have measurable, positive impacts on patient care, including timely administration of pain medication. They also said they have provided valuable medication education to the nursing staff and decreased the opportunities for adverse drug events.
            One of the program mentors, Daniel P. Hays, Pharm.D., BCPS, clinical pharmacy specialist at the University of Rochester Medical Center Department of Pharmacy and Emergency Medi­cine, Rochester, N.Y., said the program is important because there aren’t many emergency medicine pharmacists, let alone training programs for them.
            “We need to increase our numbers in these roles,” he said. “There are so few post-graduate training opportunities in emer­gency departments. We get these people excited about becoming emergency pharmacists and then jumpstart their abilities.”

Interventions and the ED Pharmacist
            Rebecca Drake, Pharm.D., BCPS, emergency medicine clinical pharmacist at Union Memorial Hospital in Baltimore, joined the program with one goal: to convince the pharmacy’s administration that her presence as a full-time ED pharmacist would increase medical interventions that potentially save lives—and money. At the time, Drake was working in the ED for only one-fifth of her workweek.
            “I really wanted to put myself in the ED full time so that people there would know who I am and could ask me questions,” Drake said.
            For her project, Drake calculated the cost savings associated with the interventions she performed in the ED for a three-month period. She recorded a savings of $8,836 for 136 interventions, which included educating patients and obtaining their medication histories.
            Drake presented her findings to the pharmacy’s administra­tion, which subsequently approved her full-time position in the ED.
            Meanwhile, Claiborne successfully integrated herself in the ED at Sentara and is working to improve the quality and safety of medication use in the institution.
            “Slowly I’m getting things accomplished,” Claiborne said. “But there’s a lot of work to do.”
            ASHP believes every hospital pharmacy department should provide pharmacy services to EDs for safe and effective patient care. But only 3.5 percent of hospitals surveyed had a pharmacist assigned to the ED for any period of time, according to the 2005 ASHP National Survey. In June, ASHP’s House of Delegates will consider approving the new Statement on Pharmacy Ser­vices to the Emergency Department, which calls on pharmacists to collaborate with other healthcare professionals to develop medication-use systems in EDs to promote safe and effective medication use.
             The ASHP Research and Education Foundation; University of Rochester; Johns Hopkins University, Baltimore; Cedars-Sinai Medical Center, Los Angeles; and the Agency for Healthcare Research and Quality collaborated with ASHP on the program.

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