The Cost-Effectiveness of a Clinical Pharmacist Intervention Among Elderly Outpatients

We estimated the cost and cost-effectiveness of a clinical pharmacist intervention known to improve the appropriateness of drug prescribing. Elderly veteran outpatients prescribed at least five drugs were randomized to an intervention (105 patients) or control (103) group and followed for 1 year. The intervention pharmacist provided advice to patients and their physicians during all general medicine visits. Mean fixed and variable costs/intervention patient were $36 and $84, respectively. Health services use and costs were comparable between groups. Intervention costs ranged from $7.50–30/patient/unit change in drug appropriateness. The cost to improve the appropriateness of drug prescribing is thus relatively low.     

Evidence-based strategies for the optimization of pharmacotherapy in older people

Geriatric pharmacotherapy represents one of the biggest achievements of modern medical interventions. However, geriatric pharmacotherapy is a complex process that encompasses not only drug prescribing but also age-appropriate drug development and manufacturing, appropriate drug testing in clinical trials, rational and safe prescribing, reliable administration and assessment of drug effects, including adherence measurement and age-appropriate outcomes monitoring. During this complex process, errors can occur at any stage, and intervention strategies to improve geriatric pharmacotherapy are targeted at improving the regulatory processes of drug testing, reducing inappropriate prescribing, preventing beneficial drug underuse and use of potentially harmful drugs, and preventing adverse drug interactions. The aim of this review is to provide an update on selected recent developments in geriatric pharmacotherapy, including age discrimination in drug trials, a new healthcare professional qualification and shared competence in geriatric drug therapy, the usefulness of information and communication technologies, and pharmacogenetics. We also review optimizing strategies aimed at medication adherence focusing on complex elderly patients. Among the current information technologies, there is sufficient evidence that computerized decision-making support systems are modestly but significantly effective in reducing inappropriate prescribing and adverse drug events across healthcare settings. The majority of interventions target physicians, for whom the scientific concept of appropriate prescribing and the acceptability of the alert system used play crucial roles in the intervention's success. For prescribing optimization, results of educational intervention strategies were inconsistent. The more promising strategies involved pharmacists or multidisciplinary teams including geriatric medicine services. However, methodological weaknesses including population and intervention heterogeneity do not allow for comprehensive meta-analyses to determine the clinical value of individual approaches. In relation to drug adherence, a recent meta-analysis of 33 randomized clinical trials in older patients found behavioural interventions had significant effects, and these interventions were more effective than educational interventions. For patients with multiple conditions and polypharmacy, successful interventions included structured medication review, medication regimen simplification, administration aids and medication reminders, but no firm conclusion in favour of any particular intervention could be made. Interventions to optimize geriatric pharmacotherapy focused most commonly on pharmacological outcomes (drug appropriateness, adverse drug events, adherence), providing only limited information about clinical outcomes in terms of health status, morbidity, functionality and overall healthcare costs. Little attention was given to psychosocial and behavioural aspects of pharmacotherapy. There is sufficient potential for improvements in geriatric pharmacotherapy in terms of drug safety and effectiveness. However, just as we require evidence-based, age-specific, pharmacological information for efficient clinical decision making, we need solid evidence for strategies that consistently improve the quality of pharmacological treatments at the health system level to shape 'age-attuned' health and drug policy.     

Drug‐related problems in elderly general practice patients receiving pharmaceutical care

Objective To describe the types of drug‐related problems identified by pharmacists providing pharmaceutical care to elderly patients in the primary care or general medicine setting, and the impact of their recommendations on drug‐related outcomes. Methods Searches of the MEDLINE, EMBASE, CINAHL, HealthSTAR, and International Pharmaceutical Abstracts electronic databases from 1990 to 2002 were conducted and a manual search of references from retrieved articles and references on file was performed. Large (n> 100) randomised, controlled studies comparing the provision of pharmaceutical care to usual care in seniors in primary care or general medicine settings were included. Two reviewers evaluated articles based on inclusion criteria and extracted data from the intervention arm of each study, resolving discrepancies by consensus. Nine original articles were included for analysis. Key findings The mean number of drug‐related problems (DRPs) identified per patient was 3.2 and the mean number of recommendations made per patient was 3.3. The most common DRP identified was not taking/receiving a prescribed drug appropriately (35.2%, range 4.7–49.3%). The most common recommendations made involved patient education (37.2%, range 4.6–48.2%). Implementation rates were generally high for all types of recommendations, with the highest being for provision of patient education (81.6%). The small number of studies available examining measures of drug utilisation and costs, health services utilisation, and patient outcomes produced inconsistent results, making it difficult to draw conclusions. Conclusions Substantial numbers and a wide range of DRPs were identified by pharmacists who provided pharmaceutical care to seniors in the primary care and general medicine setting. Pharmacists' drug‐therapy recommendations were well accepted; however, further study is needed to determine the impact of these recommendations on health‐related outcomes.     

Documenting pharmacists' interventions on a hospital's mainframe computer system

The development and implementation of a code that enables pharmacists to document their clinical interventions in the hospital's computerized patient records is described. To allow data to be entered in patient records from terminals throughout the hospital that are linked to the mainframe computer, a code was developed to summarize each pharmacist recommendation. The coded information is added to the computer entry for the specific drug requiring intervention. A computer program was developed inhouse for generating daily reports of the pharmacist interventions. During an initial 25-day study period, 300 interventions were documented; house staff physicians accepted the pharmacists' recommendations in 257 (85.7%) of these interventions. An additional 17 (6%) of the interventions resulted from physicians' requests for pharmacists' recommendations. In addition to review of all pharmacist clinical interventions, this system allows review of a specific target drug to determine compliance with institutional drug-use guidelines. Through use of the computer program developed at this hospital, information that documents pharmacists' clinical services can be entered directly into patients' records on the hospital's mainframe computer system and retrieved as useful reports.     

Effect of pharmacists' clinical interventions on nonformulary drug use

The effect on drug costs of pharmacists' interventions in reducing the use of nonformulary medications was studied in a private teaching hospital. During a four-month period, nonformulary medication request forms and pharmacist consultation logs were reviewed to determine physicians' actions taken on requests for nonformulary medications. Cost avoidance of interventions (nonformulary medication cost) and the cost of pharmacist cost) and the cost of pharmacist time for the interventions were determined. The pharmacist was able to contact The pharmacist was able to contact the physician in 388 of 394 instances in which the use of a nonformulary medication was considered. Of 230 recommendations by pharmacists to change a nonformulary drug order to one for a formulary alternative, 64.8% (149) were accepted by physicians. Of pharmacists' recommendations that were accepted, 75.8% (113/149) were from decentralized areas, which was a significantly higher acceptance rate than that for the centralized areas (24.7% or 36/149). Cost avoidance resulting from acceptance of pharmacists' recommendations during the four-month study was $2,645, or $13,573 per year; this was more than the cost of pharmacist time required to perform interventions. Pharmacist interventions to decrease use of nonformulary drugs can be cost-effective and appear to be more successful in decentralized pharmacy service areas than in areas served by a central pharmacy.     

Reduction of polypharmacy in the elderly: a systematic review of the role of the pharmacist

Polypharmacy in the elderly complicates therapy, increases cost, and is a challenge for healthcare agencies. In the context of the evolving role of the pharmacist, this systematic review examines the effectiveness of interventions led by pharmacists in reducing polypharmacy. A computerised search was conducted using Medline, Embase geriatrics and gerontology (2001 edition), the Cochrane Library and International Pharmaceutical Abstracts (IPA) databases. A manual search of articles on polypharmacy and the role of pharmacists in the therapy of the elderly and of the reference sections of all retrieved articles was also carried out. Search terms used were 'polypharmacy', 'elderly', 'aged', 'intervention' and 'pharmacist(s)'. Articles that fulfilled the following criteria were included: only elderly people were included in the study, or all ages were included but the study gave separate results for the elderly; the outcome was expressed as a reduction in the number of medications; a pharmacist participated in the study; and the study was a controlled or a randomised controlled study. We initially identified 106 articles, but only 14 studies met our four inclusion criteria. Reduction in the number of medications was not the major purpose of most selected studies but often a secondary outcome. Objectives differed, the general aim being to enhance the quality of prescribing in elderly patients. These controlled studies argued in favour of the effectiveness of pharmacists' interventions, even though the number of medications eliminated was small. Most studies were not designed to demonstrate the impact of reducing the number of drugs on the clinical consequences of polypharmacy (nonadherence, adverse drug reactions, drug-drug interactions, increased risk of hospitalisation, and medication errors). The most frequently reported outcome related to cost savings. It was therefore difficult to assess whether the interventions benefited the patient. The methodological quality of many identified studies was poor. In particular, the study objectives were often very broad and ill-defined. Polypharmacy itself has been defined in different ways and the appropriate definition may differ according to the patient population and the study setting. Further studies are needed to find the most effective way to reduce polypharmacy, especially in the frail elderly population, and to quantify the real advantages of simplifying their drug regimens in terms of improved quality of life.     

The impact of pharmacy computerised clinical decision support on prescribing,clinical and patient outcomes: a systematic review of the literature

Objectives Computerised clinical decision support systems (CDSSs) are being used increasingly to support evidence‐based decision‐making by health care professionals. This systematic review evaluated the impact of CDSSs targeting pharmacists on physician prescribing, clinical and patient outcomes. We compared the impact of CDSSs addressing safety concerns (drug interactions, contraindications, dose monitoring and adjustment) and those focusing on medicines use in line with guideline recommendations (hereafter referred to as Quality Use of Medicines, or QUM). We also examined the influence of clinical setting (institutional versus ambulatory care), system‐ or user‐initiation of CDSS, prescribing versus clinical outcomes reported and use of multi‐faceted versus single interventions on system effectiveness. Methods We searched Medline, Embase, CINAHL and PsycINFO (1990–2009) for methodologically adequate studies (experiments and strong quasi‐experiments) comparing a CDSS with usual pharmacy care. Individual study results are reported as positive trends or statistically significant results in the direction of the intentions of the CDSS being tested. Studies are aggregated and compared as the proportions of studies showing the effectiveness of the CDSS on the majority (≥ 50%) of outcomes reported in the individual study. Key findings Of 21 eligible studies, 11 addressed safety and 10 QUM issues. CDSSs addressing safety issues were more effective than CDSSs focusing on QUM (10/11 versus 4/10 studies reporting statistically significant improvements in favour of CDSSs on ≥ 50% of all outcomes reported; P= 0.01). A number of QUM studies noted the limited contact between pharmacists and physicians relating to QUM treatment recommendations. More studies demonstrated CDSS benefits on prescribing outcomes than clinical outcomes (10/10 versus 0/3 studies; P= 0.002). There were too few studies to assess the impact of system‐ versus user‐initiated CDSS, the influence of setting or multi‐faceted interventions on CDSS effectiveness. Conclusions Our study demonstrated greater effectiveness of safety‐focused compared with QUM‐focused CDSSs. Medicine safety issues are traditional areas of pharmacy activity. Without good communication between pharmacists and physicians, the full benefits of QUM‐focused CDSSs may not be realised. Developments in pharmacy‐based CDSSs need to consider these inter‐professional relationships as well as computer‐system enhancements.     

Development of a comprehensive clinical pharmacy workload documentation system

The purpose of this project was to develop a workload documentation system which captures the clinical activities of the pharmacist, as well as the pharmacist's impact on the patient's drug therapy outcomes and costs. The documentation system consists of three sections: clinical activities, clinical effectiveness indicators, and cost-effectiveness indicators. In addition to those established by the National Hospital Productivity Improvement Program-Pharmacy Workload Measurement System, other indicators are incorporated to more accurately reflect the pharmacists' daily clinical activities. Clinical effectiveness indicators of patient outcomes include the number and type of drug-related problems identified and resolved and the number of therapeutic interventions made and accepted. Cost-effectiveness is measured by pharmacists' interventions on 14 focused areas of drug therapy. Compliance with daily documentation is facilitated by use of pocket-sized cards for data collection and retrieval. This documentation system has been implemented since December 1990. Quarterly reports submitted to the Director identify changes and trends in workload. Information is used for staff justification, impact assessment of clinical service provided, identification of needs for staff development and planning future clinical directions. In order to enhance the efficiency of documentation and data analysis, future plans include computerization and evaluation of the frequency of data collection.     

Physician assessment of pharmacists' interventions--a method of estimating cost avoidance and determining quality assurance

The impact and quality of select pharmacists' interventions were assessed by four physicians with pharmacology experience. Each physician was sent 30 interventions and asked to indicate if the intervention by the pharmacist was of a positive nature and would prevent morbidity and/or mortality. They were also questioned regarding effect of the intervention on hospital stay. Each physician received 15 interventions which were, and 15 interventions which were not assessed by three other physicians. Of the 15 interventions assessed by all four physicians there was favourable agreement among the physicians with respect to the impact of the intervention with 86.7 percent (52 of 60) of the judgements indicating that the pharmacists' intervention had a positive effect on therapy. There was less agreement with regard to whether hospital stay would, and the extent to which it would, have been prolonged. Using consensus it was estimated that eight of 15 interventions would have prolonged stays approximately 3.7 days each. The use of physicians was helpful in assessing the impact of pharmacists' interventions.     

Outcomes of recommendations by hospice pharmacists.

PURPOSE: The value of pharmaceutical care recommendations made by consultant pharmacists and the outcomes of these recommendations were studied. METHODS: The study was conducted at three hospice programs, and the investigators were consultant pharmacists who shared the responsibility of providing drug therapy recommendations to the three programs. A literature search was conducted to determine if any tools had been developed to evaluate recommendations made by pharmacists in clinical practice settings. One tool was identified and adapted for use in a hospice clinical setting. Drug-related problems (DRPs) (n = 98), clinical interventions (n = 87), and outcomes data were collected by two hospice consultant pharmacists and evaluated by a panel of experts using the assessment tool. RESULTS: Ninety-eight interventions were collected and evaluated. Eighty-seven of the 98 interventions were classified as clinical interventions with specific therapeutic goals established. Of these 87 interventions, 73 (84%) were accepted by the prescriber and 56 (77%) out of the 73 helped achieve the therapeutic goals. An additional 6 (8%) interventions partially achieved the therapeutic goals. Over 75% of all of the pharmacists' recommendations achieved their intended therapeutic effect, which resulted in better management of the patients' physical symptoms. None of the accepted recommendations resulted in the patient coming to harm or having an adverse effect. Overall agreement between raters for severity and value was moderately high, 60-70% and 63-80%, respectively. Kappa scores were low. CONCLUSION: Hospice-based clinical pharmacists influenced patient outcomes positively by identifying DRPs and recommending appropriate drug therapy.     

Development of a quality use of medicines coding system to rate clinical pharmacists'' medication review recommendations

Objective: To develop a 'quality use of medicines' coding system for the assessment of pharmacists' medication reviews and to apply it to an appropriate cohort.Method: A 'quality use of medicines' coding system was developed based on findings in the literature. These codes were then applied to 216 (111 intervention, 105 control( veterans' medication profiles by an independent clinical pharmacist who was supported by a clinical pharmacologist with the aim to assess the appropriateness of pharmacy interventions. The profiles were provided for veterans participating in a randomised, controlled trial in private hospitals evaluating the effect of medication review and discharge counselling. The reliability of the coding was tested by two independent clinical pharmacists in a random sample of 23 veterans from the study population.Main outcome measure: Interrater reliability was assessed by applying Cohen's kappa score on aggregated codes.Results: The coding system based on the literature consisted of 19 codes. The results from the three clinical pharmacists suggested that the original coding system had two major problems: (a( a lack of discrimination for certain recommendations e.g. adverse drug reactions, toxicity and mortality may be seen as variations in degree of a single effect and (b( certain codes e.g. essential therapy were in low prevalence. The interrater reliability for an aggregation of all codes into positive, negative and clinically nonsignificant codes ranged from 0.49–0.58 (good to fair(. The interrater reliability increased to 0.72–0.79 (excellent( when all negative codes were excluded. Analysis of the sample of 216 profiles showed that the most prevalent recommendations from the clinical pharmacists were a positive impact in reducing adverse responses (31.9%(, an improvement in good clinical pharmacy practice (25.5%( and a positive impact in reducing drug toxicity (11.1%(. Most medications were assigned the clinically nonsignificant code (96.6%(. In fact, the interventions led to a statistically significant difference in pharmacist recommendations in the categories; adverse response, toxicity and good clinical pharmacy practice measured by the quality use of medicine coding system.Conclusion: It was possible to use the quality use of medicine coding system to rate the quality and potential health impact of pharmacists' medication reviews, and the system did pick up differences between intervention and control patients. The interrater reliability for the summarised coding system was fair, but a larger sample of medication regimens is needed to assess the nonsummarised quality use of medicines coding system.