hospital pharmacy in canada 2005-2006 hey kid … what do you do now ? jean-françois bussières b...
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Hospital Pharmacy in Canada2005-2006
Hey Kid … what do you do now ?
Jean-François BussièresB Pharm MSc MBA FCSHP
Chef, département de pharmacie et unité de recherche en pratique pharmaceutique
Professeur agrégé de cliniqueFaculté de pharmacie, Université de Montréal
Membre du comité de rédactionRapport canadien sur la pharmacie hospitalière
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Match plan
• Objective : provide participants with an overview of the alignment of hospital pharmacy practice (e.g. clinical pharmacy) with the evidence– What do we Know ?– What do we Ignore ?– What should we Do ?
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Who are we ?
• Response rate = 74 %• Teaching institutions = 26 %
Johnson N et al. Hospital Pharmacy in Canada 2005-6
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Who are we ?
• Please consider absolute numbers … but prefer ratios when available
• Always understand what’s behind the numbers
Johnson N et al. Hospital Pharmacy in Canada 2005-6
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Clinical practice models
• Clinical pharmacy has celebrated its 40th anniversary in 2006
• There are many models and philosophy• Traditional clinical services
– range of services based on a medication or a particular pharmaceutical function designed to optimize a given result for the patient; for example pharmacokinetic services, total parenteral nutrition (TPN) monitoring services and so on.
• Pharmaceutical care– organized delivery of pharmacotherapeutic services to achieve well-
defined therapeutic results. In particular, it means designing, applying and managing a therapeutic care plan of monitoring, prevention and solution of pharmacotherapeutic problems, potential or real.
• Interdisciplinary pharmacy practice• Total pharmacy practice
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Clinical practice models• Traditional (89 %) and pharmaceutical care (82 %) are
largely implemented• Pharmacy departments use both models and an
important % or beds are still non covered
Johnson N et al. Hospital Pharmacy in Canada 2005-6
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Clinical practice models
• Pharmaceutical care AND absence of clinical services have progressed over the last 10 year-period
Practice models
0%
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100%
1996-1997 1997-1998 1999-2000 2001-2002 2005-2006
Fiscal years
Pro
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f re
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(%
)
Pharmaceutical care model
Traditional clinical services
No clinical services
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Clinical practice models
• The proportion of beds covered by PC has increased while the proportion of beds uncovered has decreased
Bed coverage per practice models
0%
10%
20%
30%
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1996-1997 1997-1998 1999-2000 2001-2002 2005-2006
Fiscal years
Pro
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f re
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% of beds covered - PC
% of beds covered - TCS
% of beds Uncovered - None
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Clinical practice models
But we ignore … – If this distinction between models is still
useful and reliable to report ?– If one model is superior to the other in all
cases or some cases ?– What criteria should influence the
implementation of one model or the other ? What is the best model mix ?
– What will be the impact of the entry-level Pharm. D. on practice models
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Clinical practice models
So we have to …• Ensure that each pharmacy department
has a reproductible framework for clinical pharmacy services
• Ensure a better coherence between academia, hospital and community pharmacy practice
• Document and publish successful practices from role model
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A new entry-level Pharm. D.
Transversals• Professionnalism• Communication• Team work and interdisciplinarity• Scientifical reasoning and critical thinking• Autonomy in learning• LeadershipSpecifics• Pharmaceutical care• Service to the community• Pharmacy management and operations
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A new entry-level Pharm. D.
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A new entry-level Pharm. D.
• Module A – Drugs and the human
• Module B – Drugs and society
• Module C – Labs
• Module D – Integration activities
• Module E – practical training/internship
• Module F – optional courses
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Staffing• There are different ratios that can be used to
compare pharmacy staffing to others e.g. doses dispensed/y, case-mix index-ajusted patient-days, admission, occupied beds etc.
Gupta SR et coll. AJHP 2007; 64: 937-44.
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Staffing
• 15 FTE pharmacists/ 100 occupied beds
• 7 times more integrated pharmacists than clinical pharmacists/100 occupied beds
Pedersen CA et al. AJHP 2007; 64: 507-20.
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Staffing• 19,1 FTE/100 occupied bed (estimated
occ. Rate – 85 %) vs 14 up to 20 FTE/100 occupied bed in USA
Johnson N et al. Hospital Pharmacy in Canada 2005-6
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Staffing
Johnson N et al. Hospital Pharmacy in Canada 2005-6
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Staffing
But we ignore what …– Is the optimal staffing in terms of FTE to fulfill
adequately patient needs– Is the optimal ratio pharmacists / non
pharmacists – Should be the future role of pharmacy
technicians for non dispensing activities– Is the impact of having a non-pharmacist as a
head of pharmacy department
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Staffing
So we have to …– Collect indicators to be able to calculate ratio
(# dose dispensed, # patient-days adjusted for case-mix …)
– Agree upon key ratio to be reported at least regionally for benchmarking
– Develop indicators for ambulatory/outpatient care activities
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Time devoted to clinical pharmacy
• Only 24 % of respondants devote > 29 % of their time to monitoring medication therapy in US
Pedersen CA et al. AJHP 2007; 64: 507-20.
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Time devoted to clinical pharmacy
• 41 % of pharmacists’ time is devoted to clinical (patient care) activities in Canada
Johnson N et al. Hospital Pharmacy in Canada 2005-6
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Time devoted to clinical pharmacy
But we ignore what …– Is the optimal % of time of clinical activities for
a pharmacy department– Is the optimal % of time for clinical activities of
an individual on a daily, weekly, monthly or annual basis
– Is the optimal number of clinical specialty per individual (1, 2, more ?)
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Time devoted to clinical pharmacy
We have to …
• Agree upon a simple system to capture (bill) the nature of pharmacy services provided by individual on a regular basis
• Evaluate the optimal mix (clinical/non clinical) for productivity, retenteion and impact of pharmacists
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SpecializationOutpatient and inpatient pharmacy services
OUTPATIENT• Hematology-oncology – 80 %• Renal/dialysis – 63 %• Emergency – 54 %• Anticoagulation – 52 %• Infectious disease/AIDS – 40 %• Diabetes – 39 %• Transplantation – 31 %• Mental health – 27 %• Geriatrics/LTC – 26 %• Pain/ palliative care – 26 %• Asthma / allergy -16 %• General medicine – 14 %• General surgery – 14 %• Neurology – 13 %• Gynecology – obstetrics – 8 %• Rehabilitation – 7 %
INPATIENT• Geriatrics/LTD – 83 %• Adult critical care – 79 %• Hematology-oncology – 78 %• General medicine – 78 %• Pain / palliative care – 70 %• Cardiovasculair /lipid – 68 %• Mental health – 63 %• General surgery – 63 %• Pediatric /neonatal critical care – 56 %• Renal / dialysis – 51 %• Rehabiliation - 50 %• Hematology/anticoagulation – 46 %• Infectious disease/AIDS – 46 %• Transplantation – 45 %• Gynecology – obstetrics – 43 %• Diabetes – 41 %• Neurology – 40 %• Asthma-allergy – 37 %
Johnson N et al. Hospital Pharmacy in Canada 2005-6
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SpecializationOutpatient pharmacy services
Johnson N et al. Hospital Pharmacy in Canada 2005-6
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SpecializationInpatient pharmacy services
Johnson N et al. Hospital Pharmacy in Canada 2005-6
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Effectiveness of hospital pharmacy• Litterature search and review• Different domains
– General medication review and clinical intervention monitoring– Multidisciplinary teamwork– Patient’s own drugs and self-administration schemes– Pre-admission clinics– Patient discharge services– Shared care, primary/secondary care interface and outreach services– Outpatient service– Mental Health– Intensive care units and theatres– Patient counselling and education– Aseptic services– Non-sterile manufacturing– Pain control– Medicines information– Anticoagulant services– Pharmacokinetic and therapeutic drug monitoring services– Extended hours, residency and on-call services– Strategic medicines management, formulary services and clinical audit– Education and training– Renal services– ADR and clinical risk management– Computer support services– Pharmacist prescribing– Pharmacy technicians and ATO’s– Others
Guild of healthcare pharmacists. 2001
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Effectiveness of hospital pharmacy
Guild of healthcare pharmacists. 2001
• 10 099 articles• 13 reference database (Medline, Pharmline, EPIC, etc.)• Mainly UK publications• No statistical analysis• Most studies have positive results (publication biais ?)• Authors have identified 7 key concerns
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Specialization
But we ignore …
• How to better prioritize a clinical specialty vs another
• The evidences about the impact of pharmacist per specialty
• What level of resources should be devoted to a specific specialty
• How to recognize specialist vs generalist
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Specialization
But we have to …
• Monitor published evidences for pharmacy practice as for drug therapy
• Build business cases for clinical pharmacy with evidences, patients and professionals needs
• Recognize specialist in pharmacy
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Impact of clinical pharmacy
• Clinical pharmacy can have– A positive impact on costs– A positive impact on adverse drug event,
reaction and medication error– A positive impact on lenght of stay– A positive impact on
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Economic benefits
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Economic benefits
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Effect of pharmacists’ interventions on patient and process outcomes
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Effect of pharmacists’ interventions on patient and process outcomes
• 343 articles retrieved from 1985-2003 but only 36 included• Controlled studies, inpatient, patient outcomes
– Pharmacists’ participation on medical rounds (n= 10)
– Medication reconciliation studies (n=11)
– Drug specific services (n=15)
• Global impact– ADE, ADR or ME were reduced in 7/12
– Medication adherence, knowledge and appropriateness were improved in 7/11
– Shorten lenght of stay in 9/17
– Higher use of healthcare in one study
– No studies reported worse clinical outcome
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Association between pharmacists, clinical pharmacy and health care outcomes
Bond CA et al. Pharmacotherapy 2001; 21 (2): 129-41.
• Increasing # pharmacists/100 occupied beds is associated with a reduction in # deaths/hospital/year
• Increasing # clinical pharmacists/100 occupied beds is associated # deaths/1000 admissions
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Association between pharmacists, clinical pharmacy and health care outcomes
Bond CA et al. Pharmacotherapy 2001; 21 (2): 129-41.
• Increasing # clinical pharmacists is associated with a reduction in LOS
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Association between pharmacists, clinical pharmacy and health care outcomes
Bond CA et al. Pharmacotherapy 2006; 26 (6); 735-47
50 % des ADR/year by increasing the # clinical pharmacists/100 occupied beds from 0,9 à 5,7
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Association between pharmacists, clinical pharmacy and health care outcomes
• Medication errors/occupied bed/year rate is lower – when pharmacists are decentralised (1,74)
– or centralized with ward visits (1,93)
• Vs centralized (3,15)
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BEFORE
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PrioritizationAdmission and discharge interviews
0%
10%
20%
30%
40%
50%
60%
70%
80%
Proportion of respondants (%)
1986-1987
1987-1988
1989-1990
1990-1991
1991-1992
1992-1993
1993-1994
1994-1995
1995-1996
1996-1997
1997-1998
1999-2000
2001-2002
Fiscal years
Clinical activities w ith patients
Admission interviews
Discharge interviews
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Prioritization - Rounds and consultation with physicians and kardex rounds with nurses
Clinical activities w ith physicians and nurses
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
1986-1987 1987-1988 1989-1990 1990-1991 1991-1992 1992-1993 1993-1994 1994-1995 1995-1996 1996-1997 1997-1998 1999-2000 2001-2002
Fiscal years
Rounds with physicians
Consultation with physicians
Kardex rounds with nurses
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Prioritization Pharmacokinetic dosings
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Proportion of respondants
off ering PKD
1986-
1987
1987-
1988
1989-
1990
1990-
1991
1991-
1992
1992-
1993
1993-
1994
1994-
1995
1995-
1996
1996-
1997
1997-
1998
1999-
2000
2001-
2002
Fiscal years
Growth of PK dosing
Pharmacokinetic dosing nd
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AFTER
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Average level of service and ranking priority
Johnson N et al. Hospital Pharmacy in Canada 2005-6
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Average level of service and ranking priority
Johnson N et al. Hospital Pharmacy in Canada 2005-6
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Prescribing
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Evaluation
Johnson N et al. Hospital Pharmacy in Canada 2005-6
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Prioritization
But we ignore …
• How to prioritize amongst all clinical pharmacy activities
• How to better delegate or collaborate with other professionals without losing the essence of pharmacy practice
• How to document and evaluate theses activites
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2015 Vision
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So what’s next ?
• Find, read, understand and use evidences• Document, benchmark, evaluate and update
models, specialty areas, hierarchy of activities• Meet, discuss, move towards consensus about
pharmacist role to develop an evidence based practice model
• Question, research, answer, publish and transfer the knowledge within and outside the profession