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1 SYMPOSIUM Primry-cre setting Implementtion of drug therpy monitoring clinic in primry-cre setting JILLMARIE K. YANCHICK Mny ntionl orgniztions hve identified the optiml mngement of chronic disese sttes through eduction nd pproprite phrmcotherpy s mjor public helth issue. Published guidelines for the tretment of hyperlipidemi, dibetes mellitus, sthm, nd hypertension re rpidly becoming the stndrd of cre in mbultory medicine. 1-4 At the sme time, phrmcists hve clerly estblished their role s fcilittors of rtionl drug therpy nd providers of phrmceuticl cre. 5 Phrmcists hve been shown to hve positive impct on ptientcre outcomes by monitoring tretment plns, educting ptients nd providers, nd promoting cost-effective therpy. 6 To tp into tht potentil, Reynolds Army Community Hospitl in Ft. Sill, Oklhom, instituted phrmcist-mnged drug therpy monitoring clinic in its primry-cre deprtment. The clinic, stffed with one clinicl phrmcy specilist, begn in 1995 fter six months of preprtion. As of August 1999, its stff hd grown to two clinicl specilists, clinicl phrmcist, n ASHP-ccredited prim- ry-cre resident, phrmcy student, clinicl technicin, nd prt-time registered dietitin. This Abstrct: The development nd implementtion of drug therpy monitoring clinic in the primry-cre clinics of militry hospitl re described. To improve ptient cre nd decrese costs ssocited with treting chronic diseses, in August 1995 the phrmcy deprtment estblished drug therpy monitoring clinic. The clinic ws responsible for inititing nd monitoring tretment plns for ptients with chronic diseses, implementing clinicl guidelines, providing eductionl progrms, collecting nd nlyzing outcome dt, nd hndling requests for mediction extensions. Tretment followed existing ntionl stndrds nd Deprtment of Defense guidelines modified for the institution. The clinic begn with one clinicl phrmcy specilist, nd within yer it dded nother clinicl phrmcist nd technicin. The clinic first obtined ptients vi consulttions from providers in primry cre; this ws soon extended to ll deprtments. In ddition, the phrmcist ws vilble to see wlk-in ptients needing mediction extensions. Lter, referrls cme for inptients nd ptients seen in the emergency room for sthm or dibetes mellitus, s well s for inptients receiving orl nticogultion therpy. For fiscl yer 1999, the clinic sw 104 (±44.) ptients per month seeking mediction extensions. It lso hndled 24,87 clinicl interventions tht yer, resulting in projected nnul svings of $1,085,560. Chrt review indicted tht complince with ntionl stndrds improved drmticlly for ptients with dibetes mellitus or sthm followed by phrmcists compred with physicin monitoring during the sme period nd before the clinic begn. The wit time for reviewing lbortory results nd for ptients receiving nticogultion therpy ws eliminted, nd doses were chnged immeditely, if needed. A comprehensive phrmcist-mnged drug therpy monitoring clinic for outptients with chronic diseses cn result in positive ptient outcomes nd more costeffective cre. Index terms: Ambultory cre; Asthm; Clinicl phrmcists; Complince; Dibetes mellitus; Economics; Interventions; Ptient eduction; Personnel, phrmcy; Phrmceuticl services; Phrmcy, institutionl, hospitl; Prescriptions; Primry cre; Protocols; Stndrds Am J Helth-Syst Phrm. 2000; 57(Suppl 4):S0-4 rticle describes the development, implementtion, nd evolution of the progrm. JILLMARIE K. YANCHICK, PHARM.D., C.D.E., is Director, Drug Therpy Clinic, nd Clinicl Coordintor, Deprtment of Phrmcy/Primry Cre, Reynolds Army Community Hospitl, Ft. Sill, OK 750 Bsed on the proceedings of the ASHP Best Prctices in Helth- System Phrmcy Mngement Awrd Symposium held June 6, 2000, during the ASHP Annul Meeting in Phildelphi, PA, nd supported by n eductionl grnt from Pfizer Inc. Dr. Ynchick received monetry wrd from Pfizer, s well s n honorrium for prepring the mnuscript. Copyright 2000, Americn Society of Helth-System Phrmcists, Inc. All rights reserved /00/1202-0S0$ S0 Am J Helth-Syst Phrm Vol 57 Dec 15, 2000 Suppl 4

2 Primry-cre setting SYMPOSIUM Bckground Reynolds Army Community Hospitl is 120-bed hospitl tht provides both inptient nd mbultory services. It serves ctive duty personnel, dependents, nd retirees in the militry helth system. The hospitl hs 400,000 mbultory visits nnully nd is prt of the Medicre Subvention Project, which enbles ptients over ge 65 to be enrolled for cre t militry hospitl. In Jnury 1994, the phrmcy deprtment decided to convert from product-distribution orienttion to ptient orienttion focused on positive therpeutic outcomes. The chief of phrmcy nd the Deprtment of Defense (DOD) Phrmcoeconomic Center temed up to hire n mbultory cre phrmcy specilist who would be responsible for re-engineering phrmcy prctice t the hospitl. In August 1994, I ws hired to fill this position. Lter tht yer, in n effort to improve ptient cre nd minimize inpproprite cost expenditures, the hospitl initited n internl review of the impct of chronic disese sttes, nd I got involved in tht review. The primry-cre deprtment ccounted for the highest phrmceuticl expenditures within the institution; within tht, the respirtory ctegory ws the most expensive. We found tht mny ptients did not receive pproprite drug tretment, eduction, nd home mngement plns for sthm. The review lso reveled tht dibetes mellitus ws one of the top chief complints in the primry-cre deprtment, nd medictions nd supplies used to tret it constituted the fifth highest expenditure ctegory. Mny ptients did not receive pproprite eduction or drug tretment, nd their tretment did not meet Americn Dibetes Assocition (ADA) stndrds of cre. 2 Speedy ccess to cre ws problem, long with indequte time for prctitioners to spend with ptients t ppointments. Preliminry chrt reviews reveled tht ptients were on duplicte medictions, stndrds of cre for chronic disese sttes did not mtch ntionl guidelines, nd our emergency room ws being used for routine cre insted of cute cre. Asthm nd uncontrolled hypertension were two of the top chief complints in the emergency room, s well s the primry resons for repet emergency room visits mong our beneficiry popultion. Preventble hospitliztions for uncontrolled dibetes mellitus were lso concern. The deprtment of primry cre nd the deprtment of phrmcy worked together to develop pln for solving these problems relted to the tretment of chronic diseses. We decided tht DOD guidelines, long with ntionl tretment guidelines, would be used when possible s the primry reference documents in developing bseline ssessments nd cre plns for ptients. 7-9 Both deprtments wnted to institute the guidelines in such wy tht would best mximize provider nd ptient prticiption, improve ptient cre, decrese witing times for ppointments, nd decrese the cost of treting chronic disese sttes. Possible options included bsic provider eduction clsses, cdemic detiling, nd multifunctionl phrmcy clinic. Using totl qulity mngement methods to identify the strengths nd weknesses of ech pproch, the two deprtments decided tht phrmcist-mnged drug therpy monitoring clinic fit well with the phrmcy deprtment s new focus on ptient outcomes, nd it offered dvntges over simply offering eductionl progrms for providers. This clinic would be responsible for providing direct ptient cre by inititing nd monitoring tretment plns for ptients with chronic disese sttes; implementing clinicl guidelines; providing eductionl progrms for stff, providers, p- tients, phrmcy residents, nd students; collecting nd nlyzing outcome dt; nd hndling ptient requests for mediction extensions (refills). Implementing the progrm The first step in implementing the progrm involved deciding which clinicl prctice guidelines we would use. There were three vilble choices. Guidelines could be written de novo, existing ntionl or DOD guidelines could be incorported in totl, or existing guidelines could be modified on the bsis of specific situtions unique to our fcility. We chose to modify existing guidelines to fit our fcility. Preference ws lwys given to the DOD Phrmcoeconomic Center guidelines becuse they rely hevily on ntionl guidelines; they were lso modeled to yield specific recommendtions tht would enhnce the economic efficiency in DOD medicl fcilities. 7-9 The next step ws to collect bseline dt bout few disese sttes in the beneficiry popultion, including the number of ptients, disese severity, nd current tretment prctices. Ptients were identified vi computer dt on dmissions, emergency room visits, ICD-9 dignosis codes, phrmcy prescription records, consulttions, nd chrt review. Initilly, the clinic obtined ptients vi consulttions from helth cre providers in primry cre only. In ddition, the clinic s schedule ws plnned so tht the phrmcist ws vilble to see wlk-in ptients needing mediction refills from one clinic. After three months, consulttions were extended to ll deprtments. Developing system for monitoring ptient-cre nd economic outcomes ws lso prt of the implementtion pln. From the strt, we used the Clinitrend computer progrm to document interventions nd cost voidnce. I spent lot of time before the Am J Helth-Syst Phrm Vol 57 Dec 15, 2000 Suppl 4 S1

3 SYMPOSIUM Primry-cre setting clinic opened estblishing one-onone rpport with providers in the primry-cre deprtment, teching them how clinicl phrmcy specilist could function nd fcilitte their prctice. The physicl loction of the drug therpy monitoring clinic next to the providers helped estblish this reltionship s well. Rpport-building nd trining continue to be n ongoing process when new providers come to our institution ech yer. Evolution of the progrm The phrmcist-mnged drug therpy monitoring clinic sw its first ptient in August 1995 with one prctitioner. It operted four dys week. As mentioned previously, it served wlk-in ptients who needed mediction extensions nd provided consulttions for ptients in the primry-cre deprtment. Ptients needing mediction extensions were screened for mediction duplictions, therpeutic ppropriteness nd effectiveness, lbortory monitoring, nd timely follow-up by their primry-cre mnger before being counseled on their medictions. If the phrmcy specilist identified problem, it ws ddressed nd modified during the visit, nd the ptient received follow-up cre through the drug therpy monitoring clinic. Becuse of the overwhelming response to the clinic, phrmcy technicin ws ssigned to the clinic in October 1995 to help with dt collection, ptient check-in, nd ppointment booking. In Mrch 1996, second phrmcist ws dded to help with the expnding service. Phrmcy students from the Oklhom University College of Phrmcy begn clinicl rottions in spring 1997, nd n ASHP-ccredited primry-cre residency progrm ws initited in July of tht yer. In July 1999, the clinic dded nother clinicl specilist. The drug therpy monitoring clinic s trck record prompted multidisciplinry hospitl committee to sk us in October 1996 to begin n sthm eduction clinic. Our clinic hd demonstrted in the pst tht it ws n effective nd efficient resource for ptient cre nd costeffective outcomes. The phrmcists lso demonstrted the bility to serve s eductors, helth cre providers, nd reserchers. To improve continuity of cre from the inptient ren to the mbultory setting, beginning in April 1997 the clinic begn ccepting consulttion requests for inptients with dibetes mellitus or sthm. Eventully, system ws developed whereby ll ptients seen in the emergency room for sthm or dibetes mellitus were utomticlly referred to the service. Agin in Jnury 1998, the clinic ws clled upon to strt new service, this time n orl nticogultion service. The deprtment of primry cre requested the service in response to severl preventble hospitliztions cused by inpproprite monitoring prctices. Tble 1. Worklod for the Drug Therpy Clinic Time Period FY 1999 Q1 FY 1999 Q2 FY 1999 Q FY 1999 Q4 FY 2000 Q1 Mediction Extensions 164. ± ± ± ± ± 24.5 Experience with the progrm A key element of our progrm is ongoing monitoring of indictors nd nlysis of results, ll of which indicte tht our progrm is successful. For fiscl yer (FY) 1999, which begn in October 1998, the clinic hd 104 (±44.) wlk-in visits per month by ptients seeking mediction extensions. Before the clinic strted, more thn three times tht number of ptients requested prescription renewls from primrycre physicins ech month. The drug therpy monitoring clinic decresed the number of requests by discontinuing duplicte prescriptions nd freeing physicin time, thereby enbling them to hve more time for ptient visits. The clinic lso decresed the number of refill requests by checking ptients eligibility for cre t our hospitl nd relesing those who were ineligible. Before, 25% of the mediction refill requests by primry-cre providers were for ineligible ptients. In ddition, the clinic did not fill requests for ghost ptients ; previously 2% of the ptients hd not seen physicin for routine cre for over two yers. Before the drug therpy monitoring clinic begn, on verge ptients hd to wit 72 hours for mediction-extension request to be filled. Tht wit time hs been eliminted. During the first qurter of FY 2000, the clinic hndled 494. (±159.8) follow-up ppointments nd 62.7 (±1.5) new consulttions per month (Tble 1), compred with (±61.) nd 68.0 (±14.0), respectively, from the sme period just yer erlier. Overll, the clinic completed 8.5 (±17.0) new consulttions per month in FY Tble 2 shows the brekdown of the clinicl interventions for FY 1999 by disese stte. As shown in Tble, for FY 1999 the clinic hndled totl of 24,87 clinicl interventions, resulting in projected nnul cost voidnce of $1,085,560. The drug monitoring progrm hs hd n impct on the Number of Appointments/Month (Men ± S.D.) Routine Follow-ups New Consulttions ± ± ± ± ± ± ± ± ± ± 1.5 Fiscl yer (FY) runs from October of the previous yer through September. Q = qurter. S2 Am J Helth-Syst Phrm Vol 57 Dec 15, 2000 Suppl 4

4 Primry-cre setting SYMPOSIUM Tble 2. Distribution of Clinicl Interventions for Fiscl Yer 1999 by Disese Stte Disese Stte Dibetes mellitus Anticogultion Asthm or llergic rhinitis Hyperlipidemi Hypertension Preventive services for women Thyroid disorders Degenertive joint disese nd gout Gstroesophgel reflux disese Chronic obstructive pulmonry disese Other % (n = 24,87) phrmcy budget; it decresed from $6.8 million in FY 1995 to $5.2 million in FY Ptient outcomes Outcomes relted to the phrmcist-mnged drug therpy monitoring clinic go beyond cost svings. We lso evluted the ptient-cre outcomes relted to severl specific chronic diseses. Asthm. In cohort of 00 ptients who received intensive sthm mngement in FY 1999, the number of emergency room visits for sthm-relted conditions decresed by 88% compred with the previous yer when these sme ptients were monitored by physicins. Similrly, the number of hospitl dmissions for sthm excerbtions decresed by 92%. Upon further review, we found tht only 25% of ptients in this cohort were on pproprite phrmcotherpy s recommended by Ntionl Hert, Lung, nd Blood Institute guidelines when they cme to the phrmcist-mnged clinic (Tble 4). The mjority of ptients received lrge doses of β-drenergic gonist inhlers nd only intermittent or no inhled corticosteroid nti-in- 2 1 Includes osteoporosis prevention nd fmily plnning. Tble. Number of Interventions nd Estimted Cost Avoidnce per Yer Fiscl Yer No. Interventions Estimted Annul Svings ($) ,49 11,159 11,951 15,705 24,87 flmmtory drugs. After regimens were djusted to include routine inhled corticosteroid therpy, the men number of lbuterol inhler cnisters used per month per person decresed from 2.6 to 0.25 in this ptient cohort. No dverse drug rections relted to sthm phrmcotherpy were seen; rther, 95% of the ptients with sthm reported hving ll symptom-free dys, compred with only 11% t bseline. As result of the phrmcist s monitoring nd eductionl efforts, ptients were better ble to mnge their disese through the use of spcers, pek-flow meters, nd ction plns. Dibetes mellitus. Tble 5 shows outcomes for ptients with dibetes mellitus followed by phrmcists in the drug therpy monitoring progrm compred with those treted in the conventionl wy by physicins both before the progrm begn nd during FY Overll, 99% of our ptients met ADA stndrds of cre compred with 45% in the physicin-monitoring group in FY Tht yer, the men glycosylted hemoglobin (HbA 1c ) vlue for ptients followed by phrmcist for 12 months ws 7.6% compred with 9.05% for ptients followed by physicins; vlues less thn or equl to 8% re ssocited with decresed morbidity nd mortlity. Overll, the number of hospitliztions for ptients with dibetes mellitus decresed 90% from FY 1996 to FY Ptient prticiption in eductionl progrms lso improved. Ninety-four percent of our ptients took four-hour clss on dibetes mellitus 9,541 21,009 99, ,780 1,085,560 or hd severl one-on-one ppointments with phrmcist tht were devoted strictly to providing informtion nd nswering questions. This compred with 60% for ptients with dibetes mellitus followed by fmily prctitioners nd internists. Ptients seemed to pprecite the positive effects of the phrmcistmnged clinic. According to survey conducted in summer 1999, 96% of the ptients with dibetes mellitus reported being more stisfied with their cre since being enrolled in the drug therpy monitoring clinic. The remining 4% were eqully stisfied with their cre. Hypertension. In hypertension project, 54 ptients were switched from extended-relese nifedipine tblets to mlodipine besylte tblets with no chnge in the dverse-event profile. Blood pressure control before nd fter the conversion ws similr. The nnul cost svings resulting from the chnge ws $49,578. Orl nticogultion therpy. In Jnury 1998, we did bseline ssessment of ll outptients t the institution who received wrfrin sodium during the previous yer. Of the 59 ptients identified, 207 did not hve n Interntionl Normlized Rtio (INR) documented. Of the 152 ptients who did hve documented INRs, dverse outcomes were documented. A gol INR ws listed for only 45% of these ptients. The verge time to chnge dose fter ptient s INR ws found to be out of rnge ws 2.4 weeks, nd numerous ptients were subtherpeutic for months. Since the drug therpy monitoring clinic initited monitoring of Am J Helth-Syst Phrm Vol 57 Dec 15, 2000 Suppl 4 S

5 SYMPOSIUM Primry-cre setting Tble 4. Complince with Ntionl Guidelines for Tretment of Asthm Outcome Physicin FY 1998 (n = 00) % of Ptients Phrmcist FY 1999 (n = 00) Hd regimen tht followed NHLBI b guidelines Reported symptom-free dys Avoided trigger(s) Used spcer for inhler(s) Used pek-flow meter regulrly Hd n ction pln 0 98 Chrts of the sme group of 00 ptients were reviewed for both periods. FY = fiscl yer. b NHBLI = Ntionl Hert, Lung, nd Blood Institute. Tble 5. Complince with Ntionl Guidelines for Tretment of Dibetes Mellitus 2 % Ptients ADA Stndrd Physicin FY 1995 (n = 150) Physicin FY 1999 (n = 185) Phrmcist FY 1999 (n = 190) HbA 1c determined Foot exm done Eye exm done Thyroid tests done Lipid levels determined Lipid levels t NCEP gol N.D. b Blood pressure < 10/85 N.D. b 46 5 Blood pressure < 140/90 N.D. b Overll met ADA stndrds c N.D. b NCEP = Ntionl Cholesterol Eduction Progrm. b No dt. c Lbortory tests nd exms were completed s described in the stndrds, but no determintion ws mde tht the results were within gol rnge. nticogultion therpy in the hospitl nd clinics in Jnury 1998, there hve been no dverse events nd only five missed ppointments. As of Februry 2000, 104 ptients receiving wrfrin were ctively enrolled in the drug therpy monitoring clinic, nd 89% of the 1867 INRs documented in their chrts since the progrm begn were within gol rnge. Drug interction, medicl procedure, diet, disese stte, nd djustment by nonclinic provider ccounted for the remining 11% (5%, 2%, 2%, 1%, nd 1%, respectively). Becuse ptients re seen by phrmcist when lbortory tests re done, doses re chnged immeditely, if necessry. Discussion Our results show tht phrmcists hve n impct on outcomes for ptients with chronic disese sttes becuse of their bility to optimize nd monitor tretment plns, educte ptients nd providers, nd promote cost-effective tretment. Substntil improvements hve been seen in the number of ptients meeting ntionl stndrds for severl chronic disese sttes since the drug therpy monitoring clinic opened t our institution. The clinic is well used nd ccepted by providers, which reflects the extensive eductionl progrms we provided for physicins, feedbck from ptients, nd documented outcomes. Conclusion Our experience indictes tht comprehensive phrmcist-mnged drug therpy monitoring clinic for outptients with chronic diseses cn result in positive ptient outcomes nd more cost-effective cre. References 1. Ntionl Cholesterol Eduction Progrm. Second report of the Expert Pnel on Detection, Evlution, nd Tretment of High Blood Cholesterol in Adults (Adult Tretment Pnel II). Wshington, DC: U.S. Deprtment of Helth nd Humn Services, 199; NIH publiction no Americn Dibetes Assocition: clinicl prctice recommendtions Dibetes Cre. 2000; 2(suppl 1):S Ntionl Hert, Lung, nd Blood Institute. Guidelines for the dignosis nd mngement of sthm: expert pnel report 2. Wshington, DC: U.S. Deprtment of Helth nd Humn Services, 1997; NIH publiction no The sixth report of the Joint Ntionl Committee on Prevention, Detection, Evlution, nd Tretment of High Blood Pressure. Arch Intern Med. 1997; 157: Hepler CD, Strnd LM. Opportunities nd responsibilities in phrmceuticl cre. Am J Hosp Phrm. 1990; 47: Schumock GT, Meek PD, Ploetz PA et l. Economic evlutions of clinicl phrmcy services Phrmcotherpy. 1996; 16: Ynchick JK. Summry of the DoD/VA clinicl prctice guideline for sthm mngement in the primry cre setting. Dept Def Phrmcoecon Cent Updte. 2000; 00(4): Deprtment of Defense Phrmcoeconomic Center. Improving the clinicl nd economic outcomes of gstroesophgel reflux disese (GERD). Dept Def Phrmcoecon Cent Updte. 1998; 98(4): Deprtment of Defense Phrmcoeconomic Center. Mngement of hyperlipidemi. Dept Def Phrmcoecon Cent Updte. 1996; 96(1):1-2,A1-19. S4 Am J Helth-Syst Phrm Vol 57 Dec 15, 2000 Suppl 4

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