ASHP InterSections ASHP InterSections

October 18, 2013

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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May 9, 2013

Pharmacist Involvement Integral to Medical Home at Advocate Health

From left, a patient reviews his test results with Golbarg Moaddab, M.D., and Christie Schumacher, Pharm.D., BCPS, BC-ADM, CDE.

AS HEALTH CARE REFORM EVOLVES and providers are held to higher standards of quality and improved patient outcomes, more physicians and health systems are turning to the patient-centered medical home (PCMH) to offer comprehensive, cost-effective care.

At Advocate Medical Group, a subsidiary of the Advocate Health System in Chicago, administrators recognized the value pharmacists can bring to the medical home. When they needed a pharmacist who had experience working with heart failure patients, they contacted the Midwestern University College of Pharmacy for a candidate.

Enter Christie Schumacher, Pharm.D., BCPS, BC-ADM, CDE, assistant professor of pharmacy practice at Midwestern University Chicago College of Pharmacy, whose work with Advocate meets ASHP’s Pharmacy Practice Model Initiative recommendations for pharmacist involvement in the medical home. She is part of a PCMH that includes six primary care physicians, a cardiologist, a nurse practitioner, a physician assistant, a nurse educator, and a dietician.

Schumacher has a broad and well-integrated role in the PCMH. Through collaborative practice agreements, she initiates, discontinues, and titrates medications and provides medication reconciliation and education to improve patient adherence. She also orders and interprets laboratory values, arranges medical referrals, and provides disease-state and lifestyle education. Schumacher is also available for medication recommendations and physician consults.

A Key Member of the Health Care Team

Schumacher works closely with the team’s nurse practitioner, Monique Colbert, APN. The primary care physicians and cardiologist refer heart failure patients to Schumacher and Colbert through a “task” message in the patients’ electronic medical records.

Although physicians can select the team member whom they would like a patient to see, Schumacher and Colbert often review the medical history and make the determination themselves.

Patients who need more help with their medications see Schumacher, whereas those who need lifestyle management counseling see Colbert. Yet the two share the goals of improving patient outcomes and lessening the physicians’ load.

“We are extra help for the doctors. When patients need follow-up, the cardiologist and primary care physicians just can’t see them every two weeks. That’s where we step in and provide that in-depth care,” said Schumacher. Initial visits last about an hour, and follow-up visits last about 30 minutes.

Although Schumacher was initially tapped for her experience in treating heart failure, it soon became clear that patients needed assistance in managing coexisting conditions.

Christie Schumacher, Pharm.D., BCPS, BC-ADM, CDE

“We were seeing high A1Cs in people with diabetes, up around 10 or 11 percent, so we started making recommendations to the physicians about how to treat them. Then we did the same for patients with hypertension and dislipidemia,” said Schumacher. “The physicians asked us if we could handle treating this condition, and we went from there.”

Schumacher now uses pharmacist-created protocols and current guidelines to help her manage patients with diabetes, hypertension, dislipidemia, chronic obstructive pulmonary disease, and asthma. Plans are in the works to add chronic kidney disease to the mix.

Colbert said she has learned from Schumacher. “My background is heart failure, and Christie helped me come on board with diabetes. At first, I would see the patients with A1Cs of eight or lower, and Christie would see patients with more complex cases, but as I became more educated and more skilled, I began to take on complex patients as well.”

Proving the Case

The PCMH took six months to implement and, initially, there weren’t many patients to see: The primary care physicians and nurses were a bit wary of Schumacher conducting physical assessments. But support from the cardiologist, with whom she had worked before, helped, as did Schumacher’s own drive to show the value of pharmacist-provided care.

“I took the time to learn physical assessments. Many pharmacists aren’t comfortable with that, but it makes a difference. You need to show the physicians that you know what you are talking about,” she said. “At first, the physicians wanted us to run everything by them, but after two weeks of seeing what we could do, they told us to just go ahead [with our care].”

Although physicians still sign off on the care notes, both Schumacher and Colbert can now write prescriptions.

Golbarg Moaddab, M.D.

Goldbarg Moaddab, M.D., an internist on the team, finds the collaboration indispensible. “I can’t imagine practicing without the medical home anymore. The other professionals can be so much more thorough regarding patient history and medications, and they have more time to spend with patients than physicians do,” she said.

Advocate Medical Group is currently looking at outcome measures such as hospitalizations, readmissions, emergency room visits, blood pressure, LDL cholesterol, and A1Cs.

Regardless of how those measures come out, Moaddab said she has noticed a change among her patients.

“Before Christie was part of the medical home, it took much longer to get patients to their goals for A1Cs, blood pressure, and lipid control. Now that they are seen more frequently by other health care professionals on the team, they get there faster,” she said.

The patients appreciate the care, as well, said Schumacher, noting that for many patients, the in-depth follow-up is a new phenomenon.

“We have patients in their 60s who tell us that no one has ever sat down with them and discussed their medications,” she said. “We have a high turnout, and they like to come to their appointments. That’s going to go a long way toward increasing adherence and helping them to get better.”

–By Terri D’Arrigo

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March 25, 2013

At Wishard Hospital, Better Diabetes Care through Teamwork

Zachary Weber, Pharm.D., BCPS, BCACP, CDE, (right) counsels a diabetes patient at Wishard Hospital in Indianapolis.

DIABETES MANAGEMENT can be tricky, especially for patients who have been diagnosed and prescribed oral agents or insulin to help them control their blood glucose. Those with type 2 diabetes often also grapple with hypertension and dislipidemia and must take additional medications.

The juggling act these patients face inspired Zachary A. Weber, Pharm.D., BCPS, BCACP, CDE, clinical assistant professor of pharmacy practice at Purdue University College of Pharmacy and clinical pharmacy specialist in primary care at Wishard Hospital in Indianapolis, to approach the hospital’s endocrinologists with a working model that focused on multidisciplinary teamwork.

The resulting collaborative practice agreement between Weber and physicians in the endocrinology clinic serves as a great example of how pharmacists can be granted enhanced patient-care privileges as part of integrated care teams, one of the recommendations of ASHP’s Pharmacy Practice Model Initiative.

New patient-care privileges can include starting new medications, adjusting medication doses, and ordering relevant laboratory monitoring.

A Basis for Teamwork

The collaborative practice agreement Weber has with the endocrinology department is modeled after agreements among other pharmacists and primary care physicians in clinics throughout the Wishard system. These agreements allow pharmacists to serve as physician extenders and work side-by-side with ambulatory care physicians to optimize patients’ medication regimens.

“The evidence from the initial collaborative practice site demonstrated improved patient care, and we felt it would be beneficial to extend it,” Weber said. “We changed the primary care agreement to fit the endocrine clinic, but the agreements are basically the same throughout the system. We have one for primary care and one for specialty care.”

Rattan Juneja, M.D., associate professor of clinical medicine, who reviewed Weber’s proposal, said the agreement came at an opportune time.

“We were swamped. Our waiting lists were six to eight months long. We spoke with Zach about how to deal with patients who [were having trouble managing their blood glucose], and he came up with the idea to work directly with patients in managing their medications.”

Dr. Weber (back, far right) consults with the diabetes team in Wishard’s endocrinology clinic.

Under the collaborative practice agreement, physicians such as Dr. Juneja and his colleague Dr. Kieren Mather, M.D., associate professor of medicine, draw up diabetes management plans and oversee patient care.

Select patients are then referred to Weber, a certified diabetes educator, for the nitty-gritty of explaining how medications work and demonstrating how to take insulin.

Weber also helps to make ongoing adjustments to the medications within the written scope of the collaborative practice agreement to help patients achieve their goals. This agreement allows him to make certain adjustments without needing to seek physician approval.

“People tend to think that you send a patient to an endocrinologist, and the endocrinologist fixes the diabetes,” said Dr. Juneja. “But it’s really the patient who treats the diabetes, and physicians can’t oversee the details of diabetes management to the extent patients need because of our patient volume.”

The results thus far have been positive: Over two years in clinic, patients who received care from Dr. Weber experienced a reduction in their average A1C levels around 1.5 – 2 percent. In addition, patients’ average LDL dropped around 20-25 mg/dl, with many more achieving American Diabetes Association (ADA) goals of less than 100 mg/dl.

Similarly, the average blood pressure for Dr. Weber’s patients fell within the recommended ADA treatment goal.

 Ironing out the Details

Although the collaborative practice agreement has been successful, initially, there were a few wrinkles. To further a continuity of process, the clinic staff had to get used to having a pharmacist around and scheduling appointments for Weber.

“We wanted patients to experience checking into the clinic, going to the exam room, leaving the clinic, and scheduling appointments as a simple process, and we didn’t want the support staff to have to learn something new,” said Weber.

“But the reality is that we were adding a whole new provider. It took some time for the clinic staff to understand who I am, what I do, and how my patients should be treated as they move through the clinic as compared to the physicians’ patients.”

The team also needed to strike a balance in terms of when patients saw whom, said Dr. Mather.

“The intent is not to refer patients to Zach as an alternate approach to long-term diabetes management. Instead, the intent is to help patients overcome hurdles to get their disease on track with better control, starting early in their care through our clinic.”

Ramping up took some time, as well. In the beginning there weren’t many referrals, Weber said. “There were only a few patients. You have to show what you can do in the clinic and how you can help patients before physicians send patients your way. You have to build that trust.”

ROI Can Take Time

The hospital administration had already seen successful collaborative practice agreements among pharmacists and physicians in primary care clinics, so there were no raised eyebrows when it took over a year for Weber to have a steady stream of patients. It also didn’t hurt that he was already salaried as a professor at Purdue.

“I didn’t face too much pressure because I have a faculty appointment, but pharmacists at other health systems or hospitals might want to stress to their administrations that it could be 12 to 24 months before there’s a return on investment,” he noted. “They might have to do some convincing at first.”

Finally, there was the issue of compensation. Because Weber is salaried, his work in the clinic does not cost Wishard any extra money. Other institutions might not have the same situation, said Mather.

“Because we are an academic institution, we’re able to have it that way, but other hospitals or physicians in private practice may face a few financial challenges with that, depending on how pharmacists are licensed in their states.”

Because Wishard physicians are not compensated per patient, neither Mather nor the other physicians in the clinic are paid for supervising and signing off on Weber’s care. “But that’s fine because the collaboration is such a help to us.”

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February 25, 2013

Expansion into Prescribing at the VA

Lauren Rass, Pharm.D., a PGY1 pharmacy resident, (center left) and Lynsey Neighbors, Pharm.D., BPCS, RPD, counsel a patient.

A KEY ELEMENT of advancing pharmacy practice—and a recommendation of ASHP’s Pharmacy Practice Model Initiative—is the expansion of pharmacists’ duties to include writing medication orders.

At the Central Alabama Veterans Health Care System (CAVHCS), which serves more than 134,000 veterans in a 43-county area of Georgia and Alabama, the clinical pharmacy team has achieved this goal through a 10-year evolution.

What began with protocol-driven care in anticoagulation management has expanded into broad scopes of practice across a range of diseases and conditions. Pharmacy practice at CAVHCS now includes not only medication management, but prescribing privileges, in person and on the telephone.

Finding a Physician Champion

Expanding pharmacy practice in a health system requires strategy. When a system-wide evaluation revealed that CAVHCS wasn’t meeting its goals for lipid management, pharmacists saw an opportunity to showcase both their training and their clinical competency.

“We thought lipid management would be fairly easy to sell to management because it’s less risky than other practice areas,” said Addison Ragan, Pharm.D., BCPS, GCP, clinical pharmacy program manager. In 2002, the system opened a lipid management clinic where pharmacists had prescribing privileges under a protocol, and it wasn’t long before physicians throughout the system took notice.

“The primary care providers loved it, and they referred patients to us across the hospital setting,” said Ragan.

The following year, pharmacists moved into managing dyslipidemia in diabetes, again, under protocols. After the VA’s national clinical pharmacy leadership released guidance on dyslipidemia and diabetes and field guidance advocating broad scopes of practice, CAVHCS pharmacists worked closely with endocrinologist Neil E. Schaffner, M.D., meeting with him weekly for a roundtable discussion. The rapport that the team developed with Schaffner would later prompt him to become a physician champion for pharmacist-provided care.

Lynsey J. Neighbors, Pharm.D., BCPS, trained with Dr. Schaffner.

“He was somewhat skeptical of pharmacists stepping into this role at first, but after working with other pharmacists and later myself, he realized what pharmacists could do,” she said.

Accountability Counts

Ragan knew that if CAVHCS pharmacists wanted to work under broad scopes of practice, they would have to demonstrate their competency in quantifiable ways. The team developed competency checklists and professional practice evaluations to determine pharmacists’ knowledge and ability. She also implemented a mentoring process to improve performance as necessary. Under this system, pharmacists evaluate their peers every quarter.

“Having an accountability system in place shows leadership that you are monitoring the clinical competency of your staff,” said Ragan. “Even if there are cases where there need to be improvements, leadership can see that you are doing your due diligence.”

Such accountability helps pharmacists be their own best advocates, she added. “We become more conscientious in our documentation because we know it will be reviewed.”

When the time came to ask for expanded scopes of practice for several pharmacists, Ragan presented the evaluations to the administration, and Schaffner wrote a letter attesting to the pharmacists’ clinical competency.

With such evidence before them, the administration saw fit to grant Ragan’s request. Now, pharmacists have expanded scopes of care that allow them to prescribe and manage medications for anticoagulation, diabetes, dyslipidemia, hypertension, pain, hypothyroidism, osteoporosis, and gout, with more opportunities on the way as Neighbors dives into the world of hepatitis C management.

Saving Time and Money

Expanded scopes of care and increased pharmacist involvement in direct patient care have been time-savers for physicians and patients alike.

“Pharmacists now titrate insulin, do follow-up, work with insulin pump patients, and handle the day-to-day management of diabetes that doesn’t always fit into a physician’s schedule,” Neighbors said. She is currently training other pharmacists to take on these new roles in diabetes care.

Other pharmacists are currently handling aftercare for heart failure patients. The pharmacists meet the patients in shared appointments with cardiologists. From there, the pharmacists follow up via telephone to discuss medications, blood pressure, and post-discharge care.

Pharmacists with this expanded scope of practice have prescribing privileges that allow them to adjust medications based on the cardiologists’ goals for treatment, particularly with respect to diuretics.

“We’re hoping that, by having pharmacists engaged in diuretic management, we will be able to prevent readmissions,” Ragan said.

Pharmacist follow-up via telephone has been a boon to patients, many of whom live in rural areas and must travel as far as 80 miles to come to one of the system’s facilities. Patients aren’t charged for the pharmacists’ telephone calls, so the saved time translates into saved money, as well—enough so that the team is now testing a video telehealth program.

But beyond that, it’s just plain easier on the patients, said Ragan. “Often they’re not feeling well,  so it’s taxing for them to travel long distances for simple changes in their medications.”

Pharmacy practice continues to expand at CAVHCS, Ragan added.

“Current scopes of practice are written to be very general and broad, and we can jump into managing disease states that we wouldn’t have been able to before without completely rewriting their scopes.”

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