T H E N E W S L E T T E R O F Q U A L I T Y I S S U E S I N H E A LT H C A R E The QualityIndicator November 2001 PHARMACY RESOURCE Pharmacists, Technicians Show How To Improve Patient Care F aced with a burgeoning workload and a continuously increasing number of prescriptions to be filled, more pharmacists are asking pharmacy technicians to help them manage pharmacy care, experts say. A report on a survey conducted last year by the National Association of Boards of Pharmacy (NABP), in Park Ridge, Ill., concluded what many in the pharmacy profession suspected but could not prove: Under proper supervision, pharmacy technicians improve pharmacy services. To recognize pharmacy technicians’ roles, and the effectiveness of the collaboration between pharmacists and pharmacy technicians in advancing patient care, the Pharmacy Technician Certification Board (PTCB), in Washington, D.C., and Baxter Healthcare Corp., a medical products and services company in Deerfield, Ill., founded the annual “Innovations in Pharmaceutical Care Awards” in 1998. The awards recognize excellence in leadership and innovation in working to improve patient care, says Melissa Murer, RPh, executive director of the PTCB. Since it was founded in 1995, PTCB has certified more than 86,000 pharmacy technicians (CPhTs). The most recent award winners represent a variety of practice settings. They are the Veterans Administration CONTENTS Editorial Two Groups Vie to Develop E-Systems 2 Strategy Beta-Blocker Program Helps Cut Costs, Improve Quality of Care 3 Long-Term Care Guidelines Stress Importance of Early Alzheimer’s Diagnosis 6 Disease Management Studies Raise Concern About Weight, Antipsychotic Medication 8 Interview Pharmacists Seek to Address Work Force Issues in Connecticut 13 Medical Center, Inpatient Care Services, in Phoenix; Duke University Medical Center, in Durham, N.C.; and Zive Pharmacy & Surgical Inc., in the Bronx, N.Y. Each program offers lessons for managed care pharmacies seeking to improve care. VA Medical Center The Veterans Administration Medical Center, in Phoenix, is a 181-bed medical-surgical teaching hospital that provides 48,000 bed days of care per year. Seeking to spend more time with patients, but lacking the time to do so, the hospital’s inpatient clinical pharmacy team hired two clinical pharmacy technicians in October 1998, says Ed Foltz, PharmD, the team’s manager. At the time, his team consisted of six clinical pharmacists and two discharge pharmacists. It wasn’t until his department had an opening for a pharmacist that the hiring of two pharmacy technicians instead of a pharmacist was considered, Foltz explains. “Over the course of a few months, we, as a team, listed the responsibilities that we felt comfortable delegating to the technicians,” he says. “These responsibilities (Continued on page 11) EDITORIAL Two Groups Vie to Develop E-Systems T here’s no denying that pharmacies need better, more sophisticated systems to speed the process of receiving prescriptions and delivering medications. And new systems are being developed to improve efficiency and reduce medication errors. But the issue managed care pharmacists face is which standards will be developed. This summer, the National Association of Chain Drug Stores (NACDS) and the National Community Pharmacists Association (NCPA), both in Alexandria, Va., formed SureScript Systems Inc., a new venture designed to accelerate the adoption of an efficient, secure electronic system to connect prescribers and pharmacists directly. To be based in Northern Virginia, SureScript will be officially launched later this year. The system will connect physicians’ offices to the largest possible number of pharmacies, and those pharmacies will be able to communicate electronically with the affiliated physicians. “For an electronic system to be truly valuable to prescribers, it needs to connect them to as many pharmacies in their local market as possible,” says Calvin Anthony, executive vice president of NCPA and co-chairman of SureScript Systems. Electronic communications through SureScript Systems will maximize health professionals’ time with patients, the organizations say. “With SureScript, communications between a patient’s pharmacist and doctor will be direct and without interference by any third party,” Anthony says. Earlier this year, three pharmacy benefit managers (PBMs)—AdvancePCS, in Irving, Texas; Express Scripts, in St. Louis; and Merck-Medco, in Franklin Lakes, N.J.—formed RxHub LLC, to develop an electronic exchange system to improve prescription safety, cut costs, and develop industry standards for transmitting prescriptions electronically. The three PBMs said the new system will increase the accuracy and efficiency of prescription writing and dispensing, increase safety for patients, and cut costs for employers and health plans. Also, it will provide a standardized channel of communication to link physicians, through electronic prescribing software on handheld computers or practice management systems, to pharmacies, PBMs, and health plans. The nation’s PBMs provide pharmacy services to more than 170 million Americans. Both of these ventures aim to solve similar problems, but each wants to protect its own turf. The independent pharmacies do not want the PBMs to gain any more leverage in the dispensing of medications; the PBMs want to ensure that they are part of the solution to the problems currently plaguing the health care system. Organizers of both systems say others are welcome to join them. It will be intriguing to see which organizations join which venture. Joseph Burns, Editor 21 Stone Wall Lane Falmouth MA 02540-2219 Phone: 508/495-0246 Fax: 508/495-0247 E-mail: [email protected] 2 The Quality Indicator, Pharmacy Resource/November 2001 ADVISORY BOARD Maude A. Babington, PharmD Partner Babington Consulting, LLC Boulder, Colo. David Berenbeim, MD, MBA, FACP Vice President and Medical Director Prescription Solutions Costa Mesa, Calif. Judith A. Cahill, CEBS Executive Director Academy of Managed Care Pharmacy Alexandria, Va. Steven B. Cano, MS, FASHP Director of Pharmacy Fallon Healthcare System and Saint Vincent Healthcare System Worcester, Mass. Robert M. Elenbaas, PharmD Executive Director American College of Clinical Pharmacy Kansas City, Mo. Donna W. Howell-Smith Director, Clinical Pharmacy Programs Humana Inc. Louisville, Ky. Peter Kwok, PharmD Pharmacy Services Manager Health Plan of the Redwoods Santa Rosa, Calif. Harlan Martin, RPh, CCP, FASCP President Pharma-Care Inc. Clark, N.J. Dennis M. Williams, PharmD Chair, American Society of Health System Pharmacists, Section of Clinical Specialists Assistant Professor, Division of Pharmacotherapy University of North Carolina School of Pharmacy Chapel Hill The Quality Indicator, Pharmacy Resource, is published by Premier Healthcare Resource, Inc., Parsippany, N.J. © Copyright strictly reserved. This newsletter may not be reproduced in whole or in part without the written permission of Premier Healthcare Resource, Inc. The advice and opinions in this publication are not necessarily those of the editor, advisory board, publishing staff, or the views of Premier Healthcare Resource, Inc., but instead are exclusively the opinions of the authors. Readers are urged to seek individual counsel and advice for their unique experiences. Publisher Premier Healthcare Resource, Inc. Suite 300, 99 Cherry Hill Road Parsippany, NJ 07054 Phone: 888/457-8800 Fax: 973-316-5989 E-mail: [email protected] STRATEGY Beta-Blocker Program Helps Cut Costs, Improve Quality of Care T ypically, family physician Brian K. Solow, MD, of the Bristol Park Medical Group in Irvine, Calif., is inundated with a steady stream of mail, mainly from HMOs or other managed care companies. Recognizing that much of it is junk, he reviews what appears useful and tosses out the rest. One piece of mail recently caught his attention, however: a letter from Prescription Solutions, a pharmacy benefit management company, reinforcing the fact that betablockers should be prescribed for post-myocardial infarction patients. “Doctors don’t usually want other people telling them how to run their practices, but the letter from Prescription Solutions provided useful information,” Solow recalls. In the letter, the PBM said its Drug Regimen Review Program was designed to improve the quality of care for health plan members who had had an acute myocardial infarction (AMI). It also listed the names of patients in Solow’s practice who had been diagnosed with an acute myocardial infarction, but who did not have a record of having received a prescription for a betablocker, at least not through Prescription Solutions. Physician Education Prescription Solutions, in Costa Mesa, Calif., is a subsidiary of PacifiCare Health Systems Inc. The information that Solow received was part of its Drug Regimen Review Program that focused on the use of beta-blockers after an AMI. The goals of the program are to educate physicians working for PacifiCare on the value and life-saving effect of the treatment regime, to identify patients suitable for the intervention, and to promote the use of beta-blockers among those patients who have had heart attacks. “As a pharmacy and medical management company, we recognize that heart disease is one of the leading causes of death among Americans,” says David Berenbeim, MD, vice president of clinical services for Prescription Solutions. Annually, about 220,000 people die of heart attacks without being hospitalized, and about two thirds of those people have had prior heart attacks, he explains. Many deaths could be prevented if patients are properly diagnosed and treated properly, he adds. Southern California (USC) School of Pharmacy shows that the program has produced significant results. “Our evaluation provided evidence that contacting providers increased the likelihood by 40% that patients would be initiated on beta-blocker therapy,” says Michael B. Nichol, PhD, associate professor and chair of the USC pharmacy school. The objective of the analysis was to esti- “We initiated this program to educate doctors on the benefits of beta-blocker therapy, and our analysis shows that it saves significant dollars for health plan sponsors.” —David Berenbeim, MD, Prescription Solutions Recognizing that beta-blockers are effective in reducing the risk of a second heart attack in post-MI patients, managers at Prescription Solutions assumed that not all physicians understood the value of beta-blockers or when and how to prescribe them. “We initiated this beta-blocker program to educate doctors on the benefits of beta-blocker therapy, and our analysis shows that it saves significant dollars for health plan sponsors,” Berenbeim says. The program gives physicians the data they need to make better prescribing decisions, ultimately saving lives, he explains. An analysis of the program by researchers at the University of mate the economic effect of using beta-blockers for AMI patients as a long-term prophylaxis in the PacifiCare population in California. The USC study shows that 2,301 members of PacifiCare experienced an AMI during the review period. Of those members, 1,772 (77%) did not have a contraindication to a betablocker. Of the 1,772 members, 927 (52%) received a beta-blocker and 846 (48%) did not. Following the intervention, beta-blocker usage increased in both the intervention and control populations. The cost of beta-blockers on a per member per month (PMPM) basis in the intervention group increased from $0 to (Continued on page 4) The Quality Indicator, Pharmacy Resource/November 2001 3 STRATEGY (Continued from page 3) $1.40 by the 12th month following the intervention. The cost of betablockers in the control population remained at less than 20 cents throughout the same period. The intervention group was 1.4 times more likely to get a beta-blocker prescription after the intervention date. AMI patients who had received a beta-blocker at some point before the intervention date were 2.5 times more likely to receive a beta-blocker after the intervention than members who had no prior history of betablocker use. The USC evaluation showed that contacting providers increased the likelihood that patients would be initiated on beta-blocker therapy, Nichol comments. The program also showed that it might be useful to target the intervention for patients who had previously been initiated betablocker therapy, because that was an excellent predictor of treatment success, Nichols says. A QI Initiative The American Heart Association estimates that nearly 5 million people have a heart attack each year. Studies show that beta-blockers reduce stress on the heart by decreasing its workload. In fact, recent studies in the Journal of the American College of Cardiology and the British Journal of Medicine have underscored their value in preventing second heart attacks. Prescription Solutions developed the beta-blocker program in 1999 as a quality improvement initiative for a large Southern California health plan. “Our primary impetus for developing the beta-blocker program was the need to reinforce existing guidelines for beta-blocker use in post-MI patients,” says Alex Gilderman, PharmD, director of clinical pharmacy services of Prescription Solutions. Gilderman’s team believed that beta-blockers were underused among patients who had had an AMI, and the team had done a recent study on the use of beta-blockers among patients with congestive heart failure. The study of CHF patients revealed that beta-blocker utilization was low that listed patients identified as not currently being prescribed a betablocker. Finally, the PBM listed recommended treatments and formulary alternatives. While literature that Prescription Solutions sent was comprehensive and “The program is very effective, and I think that most physicians appreciate this state-ofthe-art information because their practices are so demanding.” —Brian K. Solow, MD, Bristol Park Medical Group in this population as well, he explains. “We used the mechanism of mixing our medical data and our pharmacy data to generate an intervention at the provider level because we needed to educate providers on the value of using beta-blockers in their post-MI patients,” Gilderman explains. As a first step, the company studied claims data to identify members who had been diagnosed with an AMI, members with contraindications to beta-blockers, and members without a history of beta-blocker drug therapy. Provider-specific reports were generated to identify which post-MI members were not currently being prescribed a beta-blocker. After studying the data, the PBM sent letters to medical directors, primary care physicians, and directors of independent practice associations. The letters explained that the Drug Regimen Review Program was designed to monitor prescription utilization and the clinical relevance of prescribing beta-blockers to post-MI patients. The letter also explained the prescribing guidelines for patients who had experienced an AMI, and included a “Prescribing Focus” data sheet describing beta-blockers and a prescribing algorithm for post-AMI. The letter also included a physicianspecific pharmacy utilization report 4 The Quality Indicator, Pharmacy Resource/November 2001 up to date, the key to the success of the program is that the PBM has been adept at making physicians want to read all of the materials, including a list of their patients who have had an AMI, Solow explains. The physician then reviews patient charts to ensure that beta-blocker therapy has indeed been prescribed for the patient if the patient is an appropriate candidate. “Prescription Solutions receives this feedback from physicians, and we log that information,” says Glenda S. Owens, RPh, manager of public affairs at Prescription Solutions. “So at any time, we can pool the data and notify a particular medical group of its compliance with post-MI patients and beta-blocker usage.” Using HEDIS Data The beta-blocker program at Prescription Solutions focuses on the requirements of the Health Plan Employer Data and Information Set. HEDIS is a data collection tool developed by employers, HMOs, and the National Committee for Quality Assurance, in Washington, D.C. HEDIS is designed to help employers to quantify and evaluate the results and value of their health plans. Prescription Solutions executives believe the Drug Regimen Review Program has been successful, and they are considering offering it to other clients, including commercial, Medicare, and government health plans, employers, and union trusts. Overcoming Obstacles The first phase of the beta-blocker program, initiated in June 1998, targeted more than 660 physicians in Southern California. After a second campaign was launched early last year, 640 more physicians were contacted. Since the implementation of Phase I, the program has reached about 1,300 physicians and more than 4,000 patients, Owens says. Moreover, the PBM estimates that the program has saved an estimated 10 lives based on predicted mortalities for the population during the study period. In addition, PacifiCare saved over $400,000 in reduced health care costs associated with cardiac readmissions over one year. To provide verifiable measurement of the postinitiative outcomes, Prescription Solutions collaborated with PacifiCare’s Health Improvement and Quality Measurement and Research Department to extract and standardize the pertinent data on medical and pharmacy utilization data taken from claims. Physician reaction has been positive, Berenbeim says. “Physicians today are exceptionally busy,” he explains. “When they can receive unbiased, clinically based information of the value of a certain type of therapy, they not only appreciate it, they use it,” he says. Doctors recognize the clinical validity of the information provided and the value that the approach could have on their patients, especially since they ultimately want what is best for their patients, he adds. While gathering the necessary data and implementing the program, Prescription Solutions experienced the typical problems a managed care organization would encounter when introducing a new initiative, Gilderman says. “We initially had some difficulty identifying the appropriate ICD-9 codes and setting up our computer database to examine medical claims and pharmacy claims,” he says. By working closely with the company’s clients, the PBM was able to solve the problems. Prescription Solutions also had to get approval from PacifiCare’s medical director for the beta-blocker guidelines and the educational materials that were disseminated. One of the advantages of the program is that the PBM executives developing the program worked closely with their newly formed health outcomes unit, which was developed around the time of the post-MI beta-blocker program. “One reason we needed the expertise of this unit was because we were getting involved with more quality ini- merge pharmacy and medical claims. This activity helps health outcomes researchers to review utilization patterns from a pharmacy perspective and shows the effect that utilization patterns have on health outcomes and total cost of care. “We think it’s important to look at the total picture of outcomes, not just the pharmacy side,” Gilderman explains. “All too often, we are concerned about increasing pharmacy spending, but we think there is another story on the medical side,” Gilderman adds. “We have documented some areas where increasing pharmacy spending might reduce medical spending, and the beta-blocker program solidified this concept in our minds.” “The program is very effective, and I think that most physicians appreciate this state-of-the-art information because their practices are so demanding,” Solow adds. Despite the success of the betablocker program, experts say initia- “Our primary impetus for developing the betablocker program was the need to reinforce existing guidelines for beta-blocker use in post-MI patients.” —Alex Gilderman, PharmD, Prescription Solutions tiatives, and we felt that it was important to have the unit’s input when designing and measuring these interventions,” Gilderman says. The health outcomes team has more than 10 members. One is a pharmacist with a PhD, and three others are Master’s-level pharmacists who have extensive backgrounds in health outcomes. “We also have several statisticians who help us conduct retrospective claims analysis by looking at pharmacy claims and medical data,” Gilderman says. Prescription Solutions has a data warehouse that helps the company to tives that address many different conditions are needed to improve quality. “More initiatives are necessary if we are going to improve overall quality in both pharmacy and medical realms,” says Nichol. “Although the beta-blocker program provided evidence of positive impact, it is clear that new interventions need to be developed that can also improve treatment outcomes for other diseases as well.” —Reported and written by Bethanne Black, in Atlanta. More information on pharmacy strategies is available on our Web site (at www.qualityindicator.com). The Quality Indicator, Pharmacy Resource/November 2001 5 LONG-TERM CARE Guidelines Stress Importance of Early Alzheimer’s Diagnosis E arly diagnosis and therapy are important for people with Alzheimer’s disease, according to guidelines recently published by the American Academy of Neurology in St. Paul, Minn. The AAN guidelines state that Alzheimer’s disease can be reliably diagnosed using a variety of tests. Early diagnosis is important because research shows current medication and care options are most effective in treating those with mild-to-moderate Alzheimer’s disease. “These guidelines, which represent a review of virtually all research on Alzheimer’s, state categorically that an early diagnosis is possible and that Alzheimer’s is treatable,” says Danny Chun, spokesman for the Alzheimer’s Association, an advocacy organization in Chicago. The guidelines, which were published in the May 8 issue of Neurology, can help to make physicians, pharmacists, and those working in long-term care more aware of treatment possibilities. The Pharmacists’ Role Pharmacists can play a significant role in educating patients and caregivers about Alzheimer’s, experts say. They can provide information about local and national agencies that offer support and educate patients and caregivers, says Kathleen Cameron, executive director of the American Society of Consultant Pharmacists Research and Education Foundation in Alexandria, Va. Pharmacists provide education about medications, including adverse drug interactions, and expected therapeutic outcomes. They monitor medication compliance, recommend adjustments to therapy, and play a role in educating other health care professionals about the disease through seminars and training sessions. The pharmacological therapy of Alzheimer’s is divided into treatment of the cognitive symptoms of the dis- ease (such as memory impairment, attention deficits, and language difficulties), and behavioral symptoms (such as depression, anxiety, agitation, aggression, psychoses, and sleep and appetite disturbances). Although there is no cure for Alzheimer’s, medication can improve quality of life and cognitive functions among those who are mildly to moderately affected, the guidelines say. Medications called cholinesterase inhibitors work most effectively for those patients and can help to alleviate certain symptoms. the disease. The guidelines also say that selegiline, an MAO-B inhibitor, also may help with some symptoms. The guidelines also call for the implementation of regular routines and activities, which can help with behavioral symptoms. Physicians may suggest strategies to assist in daily care-giving tasks, including walking or other light exercise that helps reduce problem behaviors; playing music, particularly during meals and bathing; providing a routine for daily activities; practicing skills and giving positive reinforcement to increase Pharmacists can provide information about local and national agencies that both offer support and educate patients and caregivers, experts say. Patients who receive an early diagnosis of Alzheimer’s disease can be treated with medications determined to be most effective in the early stages of dementia, says neurologist Steven DeKosky, MD, co-author of the guidelines. However, those medications do not reverse or change the progression of the disease, he says. According to the guidelines, research shows that treatment with Vitamin E also helps to alleviate some symptoms of Alzheimer’s disease. An antioxidant, Vitamin E may aid in the breakdown of free radicals that could damage brain cells in individuals with 6 The Quality Indicator, Pharmacy Resource/November 2001 independence; and considering medications to help alleviate depression, agitation, and psychosis. Improving Quality of Life To develop the guidelines, experts reviewed more than 1,000 studies on the disease. The AAN recommendations include how to recognize early signs of Alzheimer’s, how to diagnose the disease, when medication is most effective, and what types of support can improve quality of life for patients and caregivers. The multidisciplinary panel of experts that developed the guidelines included neurologists, a Today, more than two million Americans have Alzheimer’s, and that number is projected to be as high as 14 million within 50 years. primary care physician, psychiatrists, a geriatrician, a psychologist, a nurse, a social worker, family members caring for dementia patients, and representatives from the Alzheimer’s Association. The American Association of Neuroscience Nurses in Glenview, Ill., and the American Geriatrics Society in New York have endorsed the guidelines. The guidelines stress that Alzheimer’s disease is recognizable, and can be differentiated from normal aging. It can be reliably diagnosed through an examination that includes complete medical and psychiatric histories; a neurological exam; lab tests to rule out anemia, vitamin deficiencies, and other conditions; and a mental status exam to evaluate the patient’s thinking and memory. Talking with family members or caregivers should also be part of the assessment. The AAN guidelines call for early use of specific criteria for the clinical diagnosis of probable Alzheimer’s that have been established by various agencies, including criteria from the Diagnostic Statistical Manual-IV (published by American Psychiatric Publishing Inc., Washington, D.C.), and diagnostic guidelines from the National Institute of Neurological and Communicative Disorders and Stroke in Bethesda, Md.; and the Alzheimer’s Association. The Role of Education Knowledge about treatment choices enhances opportunities for both early diagnosis and treatment attempts to retard the development of the disease. “Research shows that learning about Alzheimer’s disease is one of the best ways to help patients and their families,” says Bill Thies, vice president of scientific and medical affairs at the Alzheimer’s Association. The biggest risk factor for Alzheimer’s disease is growing old. Alzheimer’s is an ultimately fatal disorder that begins to assault the brain years before problems with memory or learning make the disease’s presence apparent, says Trey Sunderland, MD, chief of geriatric psychiatry at the National Institute of Mental Health in Bethesda, Md. Disease Stages The disorder is rare in people younger than age 60, but its frequency doubles every five years after age 65. According to the Alzheimer’s Association, it affects one in 10 people over age 65 and nearly half of those over age 85. In the next halfcentury, as the population ages, the number of Americans with Alzheimer’s disease will quadruple. The current total is estimated at between two million and four million and is projected to be as high as 14 million by 2050. More than 19 million Americans say they have a family member with the disease. The average lifetime cost per Alzheimer patient is $174,000 according to the Alzheimer’s Association. The AAN guidelines incorporate warning signs of common symptoms for the disease that were developed by the Alzheimer’s Association. Individuals who exhibit several of these symptoms should see a physician for a complete examination. The symptoms include memory loss that affects job performance skills; difficulty performing familiar tasks; problems with language; disorientation to time and place; poor or decreased judgment; problems with abstract thinking; misplacing objects; changes in mood, behavior, or personality; and loss of initiative. Alzheimer’s is a particularly insidi- ous disease because of the slow progression of symptoms. In fact, many years may pass before the patient presents for evaluation, experts say. The average clinical course of the disease from diagnosis to death is typically five to nine years, although this time may vary, according to research by Marshall Folstein, MD, chairman of the Department of Psychiatry at Tufts University School of Medicine, a division of the New England Medical Center in Boston. The three stages of Alzheimer’s disease—early, middle, and late—correspond to the severity of symptoms. Clinical Issues As the disease progresses to the late stage, the patient’s ability to communicate and function independently deteriorates further, says Folstein. Short- and long-term memory and language skills deteriorate dramatically, and patients may be unable to initiate speech or may become mute, experts say. Cells in the motor cortex of the brain are affected, and patients may be unable to walk unassisted and may become bedridden and dependent on caregivers. Death of the Alzheimer’s disease patient is usually due to infection, aspiration, embolus, or malnutrition. Because a definitive diagnosis of Alzheimer’s disease can be made only through an autopsy, a clinical diagnosis of probable Alzheimer’s relies on clinical criteria and the exclusion of reversible causes of dementia, say experts. Using the available criteria, Alzheimer’s disease can be accurately diagnosed in 86% to 92% of cases, according to researchers. —Reported and written by Martin Sipkoff, in Gettysburg, Pa. More information on pharmacy strategies is available on our Web site (at www.qualityindicator.com). The Quality Indicator, Pharmacy Resource/November 2001 7 DISEASE MANAGEMENT Studies Raise Concern About Weight, Antipsychotic Medication R ecent studies show a significant relationship between weight gain and the use of atypical antipsychotic medications among patients being treated for schizophrenia. The relationship is of sufficient concern to researchers to warrant considering weight gain as a modifiable health risk in the choice of atypical antipsychotics, experts say. This relationship is particularly worrisome because weight gain can lead to diabetes and heart disease, researchers say. Although a causal relationship between the use of atypical antipsychotics and diabetes “has not been definitively proven, the number of cases reported in the literature suggests there might be an association between atypical antipsychotic medications and diabetes mellitus,” says John Muench, MD, who has studied the issue. “Physicians who care for patients with schizophrenia should be aware of this possible association.” Muench is a physician with the Department of Family Medicine at Oregon Health Science University in Portland. Unintended Consequences A casual relationship between antipsychotic medications and weight gain has been established, say experts. Weight gain associated with antipsychotic medication use has been a concern to physicians and pharmacists since conventional antipsychotic drugs, such as chlorpromazine, were introduced in the late 1950s, says Herbert Meltzer, MD, a psychiatrist and professor in the Department of Psychiatry at Vanderbilt University School of Medicine in Nashville. That concern has been growing in recent years, he says, because the medical community has observed an increased risk of weight gain as a result of the use by patients of the atypical antipsychotic drugs introduced in the 1990s. The atypical antipsychotic drugs appear to result in a significantly greater increase in weight than the older drugs do, researchers say. “It is troubling that some atypical antipsychotic drugs appear to have a greater weight gain liability than the conventional antipsychotic drugs. In addition, some atypical antipsychotic drugs have adverse effects on blood levels of lipids and glucose,” Meltzer says. Because the relationship between weight gain and diabetes is well known, “potential weight gain through the choice of antipsychotic medications should be of concern in treating patients with schizophrenia, particularly those whose family history implies a propensity toward diabetes,” says John Newcomer, MD, an associate professor of psychiatry at the Washington University School of Medicine in St. Louis. “With regard to weight gain, the choice of a particular antipsychotic drug should defi- nitely be considered a modifiable health risk.” Newcomer is a leading researcher in the metabolic side effects of atypical antipsychotic drugs. Reports by Meltzer and other researchers who examined the relationship between atypical antipsychotic drugs and weight gain were published this year in a special supplement of the Journal of Clinical Psychiatry (issue 62, supplement 7), by Physicians Postgraduate Press Inc., in Memphis, Tenn. In the supplement, researchers reported on a review of the evidence of weight gain among patients with schizophrenia who were treated with atypical antipsychotic drugs. “The results clearly demonstrate that this problem should be of concern to every clinician,” Meltzer writes in his introduction to the supplement titled, “Weight Gain: A Growing Problem in Schizophrenia Management.” The Pharmacists’ Role As part of the medical community, pharmacists should be aware of the data being gathered by studies on atypical antipsychotic drugs because pharmacists are in a position to advise patients and physicians on possible (Continued on page 9) “Potential weight gain through the choice of antipsychotic medications should be of concern when treating patients with schizophrenia, particularly those whose family history implies a propensity toward diabetes.” —John Newcomer, MD, Washington University School of Medicine 8 The Quality Indicator, Pharmacy Resource/November 2001 DISEASE MANAGEMENT (Continued from page 8) side effects of prescribed medications, says Tricia Cash, PharmD, owner of Talbert Consulting in Stanley, N.C. “Pharmacists play a vital role in recommending approaches to maximize efficacy, ameliorate adverse effects, and identify reasons for the patient noncompliance encountered with antipsychotic medications,” Cash says. “Many clinicians are turning to atypical antipsychotic drugs for improved efficacy and reduced adverse effects. Because of their better side-effect profile, better compliance, and greater efficacy, the new antipsychotic medicines are now considered first-line medications in the treatment of schizophrenia and related illnesses. Pharmacists and other clinicians should become familiar with this new class of medications.” Safety is a key issue when evaluating antipsychotic therapies, experts say. Older agents were marked by extrapyramidal side effects (EPS) and tardive dyskinesia (TD). EPS can include grogginess or lack of focus. TD is involuntary jerky movements associated with long-term use of antipsychotics. Minimal or no EPS is the most salient defining clinical feature of the newer atypical antipsychotic medications, contributing to their widespread adoption. However, other safety concerns, such as weight gain, have resulted in renewed attention for these drugs. The evidence of a relationship between weight gain and antipsychotics is very strong, say the studies published in the Journal of Clinical Psychiatry supplement. “Data strongly suggest that many antipsychotic drugs, especially the so-called new or atypical drugs, are associated with weight gain,” says Daniel E. Casey, MD, professor of psychiatry at the Oregon Health and Science University in Portland, and director of psychiatry and psychopharmacolo- gy research at the Veterans Administration Medical Center, also in Portland. Casey was co-author of a study in the supplement titled, “The Pharmacology of Weight Gain With Antipsychotics.” Casey’s study and others conclude that weight gain should be a consideration when physicians prescribe or pharmacists dispense antipsychotic medications. Researchers agree that safety issues, especially those related to the comor- treatments for certain patients, including the number and types of EPS. More conclusive research on whether atypical antipsychotic drugs contribute directly to an increased rate of diabetes mellitus or contribute indirectly, through weight gain, is ongoing. Therefore, Newcomer and other researchers say physicians and pharmacists should be aware of existing research and data when making decisions about which drugs to use. Researchers agree that safety issues, especially those related to the comorbid symptoms of weight gain associated with diabetes, are a major concern when patients are being treated with atypical antipsychotic drugs. bid symptoms of weight gain associated with diabetes, are a major concern when patients are being treated with atypical antipsychotic drugs. “These drugs are of enormous therapeutic benefit to many patients,” Casey says. “Although they generally have a lower burden of side effects than older agents, many promote substantial weight gain, a concern to the patients within the schizophrenia population, which is already prone to an increased mortality rate from cardiovascular disease, epilepsy, accidents, lung cancer, substance abuse, and treatment refusal. Evidence shows that increased weight gain contributes significantly to impaired glucose tolerance (which can result in diabetes) and hypertension (which can result in cardiovascular disease).” More Research Needed The degree of weight gain associated with specific antipsychotic drugs will vary depending on many factors, including a hereditary disposition toward obesity and preexisting weight. Variations also are found in the overall effectiveness of specific “I am not prepared at this point to recommend one drug over another for all patients,” Newcomer says. “But weight gain is such a significant issue that it must be considered.” The effect of atypical antipsychotic drugs on brain chemistry apparently is a causal factor in weight gain among patients, Casey says. But the precise nature of that effect—in other words, which chemical interactions caused by specific drugs result in weight gain— has not yet been established. Given that atypical antipsychotic medications have broad pharmacologic profiles, it is likely that multiple neurotransmitter systems and receptors are affected by antipsychotics moderate weight gain, including the systems that govern appetite, he explains. Many patients with schizophrenia who are being treated with atypical antipsychotic drugs report a greatly increased appetite, particularly cravings for carbohydrates, says Lorraine Willows, a clinical dietitian at Kingston Psychiatric Hospital in Kingston, Ontario. “I have seen other patients with schizophrenia, however, who have gained significant weight (Continued on page 10) The Quality Indicator, Pharmacy Resource/November 2001 9 DISEASE MANAGEMENT (Continued from page 9) with little or no increase in appetite,” she says. “Weight gain tends to begin quickly and continue for an extended period, up to and beyond one year.” The issue of weight gain is particularly troubling as it concerns patients with schizophrenia. Several studies conducted over the last several years indicate that between 30% and 60% of such patients are obese when they begin treatment, possibly the result of unhealthy eating habits and lack of exercise, says David Allison, PhD. Allison is a professor and researcher at the Department of Biostatistics at the University of Alabama in Birmingham. He was co-author, with Casey, of a study titled, “Antipsychotic-Induced Weight Gain: A Review of the Literature,” in the journal supplement. Another important factor for physicians to consider when prescribing antipsychotic medications is that as a result of their erratic behavior, patients with schizophrenia tend to receive sporadic and often inferior medical care. “The information we have on obesity among patients with schizophrenia suggests that weight is a substantial problem that is likely to be impairing the health of those individuals, especially because many of the adverse effects of obesity are conditions for which schizophrenic patients tend to be underdiagnosed and undertreated,” Allison explains. Enhanced Efficacy Since they were introduced in the 1950s, the conventional antipsychotic agents have effectively controlled the symptoms of schizophrenia. Weight gain was observed with the use of the conventional antipsychotics, but that side effect was “overshadowed by the other substantial side effects of the older generation of neuroleptic agents,” Meltzer says. Physicians and pharmacists focused on the prevalence of EPS, for example, and little research was conducted on associated weight gain. The older drugs frequently produce TD, says Michael J. Burns, MD, a medical toxicologist with the Division of Toxicology in the Department of Emergency Medicine at Beth Israel Deaconess Medical Center in Boston. “The high incidence of EPS and TD often leads to patient noncompliance and a high incidence of treatment failure and disease relapse,” he says. Burns has written about atypical antipsychotic drugs and EPS, including an article, “The Pharmacology and Toxicology of Atypical Antipsychotic in February 2001). “Clinically, atypical agents achieve an enhanced efficacy for the full spectrum of schizophrenic symptoms, have a superior side-effect profile, and demonstrate improved patient compliance,” Burns says. “Because of their superior profiles, the atypicals are rapidly replacing conventional agents for nearly all schizophrenia subgroups, including first-episode, treatment-resistant, partially responding, relapsing, and stable-but-chronic patients.” “The clear beneficiaries of this new pharmacotherapy of schizophrenia are the millions of patients afflicted with this disease,” Burns continues. “Because of their better side-effect profile, better compliance, and greater efficacy, the new antipsychotic medicines are now considered first-line medications in the treatment of schizophrenia and related illnesses.” —Tricia Cash, PharmD, Talbert Consulting Agents,” in the January issue of the Journal of Toxicology: Clinical Toxicology, published by Marcel Dekker Inc. in New York City. “The need for antipsychotic agents with improved efficacy and side-effect profiles led to the development of atypical antipsychotic agents,” Burns explains. The atypical antipsychotics introduced in the 1990s represent “a new era in the pharmacotherapy of psychotic disorders,” he adds. Antipsychotic agents are considered atypical if they produce minimal EPS at clinically effective antipsychotic doses, have a low propensity to cause TD, and treat the symptoms of schizophrenia effectively. Since 1990, the Food and Drug Administration has approved five atypical antipsychotics: clozapine, risperidone, olanzapine, quetiapine, and ziprasidone (which was approved 10 The Quality Indicator, Pharmacy Resource/November 2001 “Since their introduction to the U.S. market, the atypical agents have largely displaced traditional agents as first-line drugs for the treatment of schizophrenia. Although the costs for atypical agents are much higher, pharmacoeconomic studies have suggested that these costs are offset by improved patient outcomes and reduced rates of hospitalization.” The key issue today, says Newcomer, is for clinicians to understand and appreciate the implications of potential adverse events, such as weight gain, in treatment decisions. “We are reaching a stage where we are becoming able to make more informed treatment decisions for patients with schizophrenia,” he says. —Reported and written by Martin Sipkoff, in Gettysburg, Pa. More information on pharmacy strategies is available on our Web site (at www.qualityindicator.com). COVER STORY (Continued from page 1) encompassed the steps involved in baseline screening for potential medication errors and data collection.” Specifically, the pharmacy technicians responsibilities include: • Interviewing patients on admission to verify allergies, medication use, and compliance • Screening laboratory and microbiology reports for predefined outlying values • Coordinating the pharmacists’ continuity-of-care forms, including prescriptions the patient has received both in and out of the hospital • Calculating creatinine clearances when indicated by lab results showing elevated levels • Screening for and monitoring of deep vein thrombosis prophylaxis; stress ulcer prophylaxis; blood sugar and vital signs; and total parenteral nutrition orders and lab work. With the technicians added to the department, the pharmacists are freed up to accompany physicians on their rounds as part of various medical, surgical, and critical care teams. The department has also seen a number of significant improvements. For example, lab data and medication profiles are screened more consistently for potential errors; allergy and medication use is verified more consistently; and coordination of patient information has improved. An Academic Medical Center In a program similar to that of the Phoenix VA hospital’s inpatient pharmacy program, the Duke University Medical Center re-engineered operations in its pharmacy department. The result was that pharmacy technicians had more time to devote to clinical activities—something they had expressed great interest in before the re-engineering. Unlike the technicians in the VA’s program, however, pharmacy technicians at the medical center had been working within the pharmacy department for several years, explains Michelle Giesler, PharmD, a clinical pharmacist in the Division of Surgery. The Division of Surgery currently has 236 beds in nine units. Before the restructuring, pharmacists and technicians worked entirely out of pharmacy satellites, meaning that their location was set apart from the central pharmacy in the hospital. ity and communication capabilities of pharmacists and technicians. The pharmacists were given laptop computers, and technicians were given access to mainframe order-entry computers that could facilitate their ability to do their jobs in the “hub” of patient care activity—on the patient care floors—versus from a distance, such as their former locations at the satellites. Technicians also were given pagers so that the pharmacists and health care providers in patient care units could reach them quickly. When a medical center added technicians to its pharmacy department, the pharmacists were freed up to accompany physicians on their rounds as part of various medical, surgical, and critical care teams. All communication between physicians and other providers in patient care units and pharmacy staff in the satellites occurred by telephone or through nursing personnel visits. Under this arrangement, technicians’ responsibilities included making hourly trips from the pharmacy to each patient care area to collect orders and deliver medications, entering physician orders into the pharmacy computer system, preparing medication orders for delivery, preparing reports for the pharmacists, and collecting quality improvement data. The restructuring of the department resulted in several changes that promoted a patient-focused interdisciplinary partnership that included technicians as key members of the team of health care providers. Now, pharmacists and technicians work closely and are assigned to specific patient care units. Under the current arrangement, two technological changes were introduced that facilitated the mobil- The tasks considered for reassignment to technicians were evaluated based on the needs of the pharmacy and were ranked in terms of value to the pharmacists. Pharmacists and technicians selected the tasks to implement, and then the technicians were trained in completing them. Clinical Assignments One of the new clinical tasks that the technicians assumed involved collecting data for pharmacokinetic monitoring. Technicians were asked to collect routine daily lab values for patients with current running orders for aminoglycosides and vancomycin and for starting a new pharmacokinetic sheet on receipt of a new order. Another clinical task involved collecting allergy data. Technicians were asked to collect data on patients’ allergies and to clarify reactions to allergies listed in the medical chart, as necessary, thereby freeing up pharmacists from that responsibility. One result of having the techni(Continued on page 12) The Quality Indicator, Pharmacy Resource/November 2001 11 COVER STORY (Continued from page 11) cians assume these new clinical roles is that pharmacists have more time to participate on rounds with physicians and can be more involved in drug therapy decisionmaking, including advising physicians on appropriate drug use, advising nurses on proper medication administration, and counseling patients on drug therapy. What’s more, technicians have expressed improved job satisfaction in their new roles and the teamwork approach has helped to reduce costs and improve efficiencies in patient care, Giesler says. A Community Pharmacy Zive Pharmacy & Surgical Inc. has served the Bronx, N.Y., for more than 30 years. Recently it formalized its disease state management efforts into Zive Disease State Management Co. A family-owned pharmacy that specializes in treating patients with numerous diseases, including asthma, diabetes, and hypertension, Zive Pharmacy has developed an educational program for persons with HIV that has resulted in improved medication adherence and improved patient satisfaction. Central to the program is a pharmacy technician who is a patient services manager. The pharmacy employs three pharmacists, including Joel Zive, RPh, the son of the company’s founder. Since 1993, when the pharmacy began seeing people needing HIV medications, Zive had noticed that the rate of medication compliance among this population could be improved. “Typically, people with HIV must take a multitude of retroviral medications, which can exceed 20 pills a day,” Zive says. “The side effects can be debilitating, and patients can get discouraged.” Poor medication adherence reduces treatment options, quality of life, and survival time, he says. Aware of how techs can improve a practice, Zive hired a certified pharmacy technician in 1999 to help improve adherence. The technician, Jay Hager, CPhT, established a position of HIV patient service manager for the practice, Zive says. Hager has over 25 years in pharmacy practice and a degree in community health education. “We knew we had to do more than call people on the phone to remind them to refill their prescriptions,” Zive says. Zive, Hager, and the other two pharmacists integrated the dispensing function of the pharmacy with intensive patient medication education and counseling. As a first step, the pharmacy team began tracking lems that may require intervention by a pharmacist or a physician. In addition, Zive also conducts regular HIV/AIDS educational meetings in the community. For the last six years, for example, the pharmacy has conducted community awareness days on asthma, diabetes, and hypertension. It also conducts hypertension screenings. The Technicians’ Role In tracking patient adherence rates for 12 months last year among the patients with HIV, adherence rates ranged from 85% to 94%, Zive says. Though no baseline adherence rates were calculated, the national average for antiretroviral adherence is approx- The pharmacy technicians have more job satisfaction in their new roles, and the teamwork approach has helped to reduce costs and improve efficiencies in patient care. patients’ medication refill rates, which were collected in a computer database that was separate from the prescription records. Armed with this information, the team could see the population’s compliance patterns and develop improvement strategies. In addition to refill rates, Zive says that other lab data, such as CD4 viral load (which shows the degree that the HIV has progressed), help to form a picture of each patient’s overall health status. A file is developed for each new patient, and a member of Zive’s team schedules a time to meet with each patient. At this 20-minute meeting, the team member asks a series of questions related to the person’s health and quality of life. Hager and Zive review the information gathered and develop a written treatment plan. The sheet is printed for the patient and reviewed by the one of the pharmacists, who can identify any prob- 12 The Quality Indicator, Pharmacy Resource/November 2001 imately 30%, he adds. “In summarizing the achievements of the Innovations Award winners, each had a belief that processes could be improved and that techs had a crucial role to play in making this happen,” says Bruce Wearda, RPh, pharmacy manager for Long’s Pharmacy in Bakersfield, Calif., and one of the award judges. “We also need to recognize that they responded voluntarily, under no obligation other than what their vision dictated.” Murer agrees, saying, “We take great pride in the innovations award program. Efforts to enhance patient care, reduce medication errors, and manage patients’ chronic diseases serve as best practices for the over 86,000 CPhTs nationwide.” —Reported and written by Susan Howell, in Fairport, N.Y. More information on pharmacy strategies is available on our Web site (at www.qualityindicator.com). INTERVIEW Pharmacists Seek to Address Work Force Issues in Connecticut Margherita Giuliano, RPh, has been executive vice president of the Connecticut Pharmacists Association in Rocky Hill for the past two years and has been a practicing pharmacist for 20 years. Giuliano is a member of the Connecticut Pharmacy Coalition for Patient Care, a group of pharmacists, regulators, and educators that seeks to foster changes in how pharmacies operate. In this interview, she discusses the goals of the coalition and issues the pharmacy profession faces with contributing editor Richard L. Reece, MD. Q: A: What is the mission of Connecticut Pharmacy Coalition for Patient Care? The coalition was formed in May 2000 to address the challenges facing our profession. It is composed of hospital, long-term care, independent, and chain pharmacists, as well as state regulators and representatives from the state pharmacy commission and the University of Connecticut School of Pharmacy. What are some of these challenges pharmacists face? The first challenge is to address the shortage of pharmacists. In 1999, a study of the pharmacy work force by the federal Health Resources and Services Administration (HRSA) clearly indicated evidence of a critical pharmacist shortage. One factor contributing Q: A: to the shortage is that retail pharmacy, or community pharmacy, is no longer very appealing to pharmacists and other professionals in the field. Also, more women have entered the profession, and women are more likely to seek part-time hours. Finally, other career opportunities, such as working for pharmaceutical manufacturers or educational institutions, have drawn pharmacists out of traditional jobs. The work force shortage is exacerbated by the concurrent growth in the number of prescription medications available to the public. Prescription volume is estimated to double within the next four years, and will increase even more quickly if Medicare pharmacy benefits are expanded. At the same time, the pharmacy work force is expected to increase by only about 6%. Therefore, a real crisis is developing. Third-party payers represent another challenge. Those in the pharmacy profession have faced years of difficulties in dealing with these payers, which have an excessive role in making medical judgments that affect the delivery of health care in the practice of pharmacy. Another problem with payers is inadequate reimbursement. Pharmacists are simply not being reimbursed for cognitive services that they offer to patients. Reimbursement is based solely on product, with no consideration of the daily professional services pharmacists provide to patients. As a result, reimbursements are insufficient to sustain the profession. Pharmacy is a health profession in a retail business. Finally, pharmacists are experiencing tremendous burnout and frustration because they are spending a significant amount of time resolving insurance issues. Pharmacists are educated to help patients manage drug therapy; instead, they spend 20% or more of their time dealing with insurance issues, rather than taking care of patients. Given that pharmacists work in a fragmented industry, how do they achieve any collective bargaining leverage with regard to managed care plans? Pharmacists have no leverage, which has always been an important issue for us. Managed care companies argue that we have negotiating leverage because we do not have to accept the contract being offered. Realistically, if a pharmacy is in an area where 20% of its patient base is covered by a particular insurance plan, the pharmacy has to accept that contract. The options for pharmacists, therefore, are dying quickly without the contract or dying slowly after signing it. Is your plight similar to that of physicians, who are between managed care companies and patients? Yes. Like physicians, our profits are being squeezed. Reimbursements are so low that our profit is based on prescription volume. Pharmacy has always been a Q: A: Q: A: (Continued on page 14) “Reimbursement is based solely on product, with no consideration of the daily professional services pharmacists provide to patients. As a result, reimbursements are insufficient to sustain the profession.” The Quality Indicator, Pharmacy Resource/November 2001 13 INTERVIEW (Continued from page 13) product-based service, and so pharmacy profits are caught between drug costs and decreasing drug reimbursements. As a result, pharmacies’ net profits have steadily been decreasing. Pharmacies are currently working on a net profit of around 2%, and despite efficiency improvements, pharmacists are struggling to make ends meet. What’s more, patient safety is affected. Pharmacists want to fill prescriptions correctly and safely because they have their patients’ best interests at heart, but pharmacists who are under pressure could possibly make errors. How does the coalition propose to address these issues? In July, we approved a position paper that suggests changes in third-party reimbursement formulas and state laws and regulations. In general, we want to guarantee sufficient manpower in the profession to meet the escalating demand for pharmacy services, ensure proper support in meeting this demand, and allow pharmacists to become more involved with the patients they serve. What are the changes in reimbursement you suggest? The coalition believes that pharmacists need to transition from a product-based system to a patient-based system of reimbursement. We want pharmacists to be paid for the services they deliver, not just the number of prescriptions they dispense. The plan outlines such a change in third-party reimbursement formulas. Reimbursement should include a fair price for the product, a reasonable fee for dispensing that product, and fair reimbursement for the time the pharmacist spends on utilization review and patient counseling. The plan also calls for reducing the pharmacist’s role in haggling with insurers over which pills they will pay for; this chore eats up an inordinate amount of a pharmacist’s time. The Q: A: Q: A: pharmacist’s role in dealing with insurers over plan issues should be reduced and pharmacists should spend more of their time educating patients on the proper use of their medications. What changes will allow you to focus more on patient service? Pharmacists play an important role in educating patients on their medications. But pharmacists spend more than 20% of their time resolving third-party reimbursement issues. Relieving these issues will free up valuable time that could be spent with the patient. Furthermore, several solutions center on the use of technology, including robotic systems that can provide Q: A: requirements are met, such as the presence of advanced technology or enhanced education for technicians. The commission has recently appointed a task force to review technician ratios and suggest changes for the next legislative session. We also promote regulatory changes that will support pharmacists in managing patient medication therapy. For example, approximately 30 other states allow collaborative practice between pharmacists and physicians. Connecticut law should also allow pharmacists and doctors to work collaboratively so that pharmacists can adjust medications that now require physician approval. We need to amend the statutes and regulations “We need to amend the statutes and regulations so that we can use our skills in the direct management of the patient’s medication therapy.” relief from repetitive and mechanical tasks. Using advanced technology also can result in fewer medication errors. So, these technologies have the potential to enhance operational efficiencies and improve safety. The state Department of Consumer Protection reviews computer systems and some robotics to ensure compliance with state laws. We have to amend regulations to free pharmacists from mechanical functions that do not require our specialized professional judgment. In addition, a larger number of pharmacy technicians per pharmacist would free pharmacists to spend more time with patients. In a community setting, the ratio is two technicians to one pharmacist, and these technicians must be under the direct supervision of the pharmacist. The Connecticut Commission of Pharmacy has a provision that a community pharmacy can request a three-to-one ratio if certain 14 The Quality Indicator, Pharmacy Resource/November 2001 so that we can use our skills in the direct management of the patient’s medication therapy. Disease management is another way pharmacists can focus on patient care. Many pharmacists have continued their education to receive credentialing in certain disease states because they know the value of patient education regarding drug therapy. Pharmacists can play an active role in counseling patients suffering from chronic diseases, such as hypertension, diabetes, hyperlipidemia, and asthma. The disease management counseling and medication management that pharmacists provide could help avoid costly hospital visits and ultimately save money. Is part of your goal to ensure that pharmacists play a role in the clinical treatment team? Yes. Pharmacists are important members of the health care team, but they need to have greater Q: A: INTERVIEW involvement. Pharmacists are accessible to patients, who probably see a pharmacist more often than any other health care provider. The education that pharmacists have can be leveraged to a greater degree. After all, pharmacists are the drug experts. They go through six years of clinical education, which when combined with their access to patients, enable them to play an important role in patient care. What is the current relationship outside of institutions between physicians and pharmacists? Even within an institution, where physicians and pharmacists collaborate, the pharmacists legally cannot change medications without approval from the physician. When we talk about collaborative practice, we refer to a voluntary agreement between physicians and pharmacists to manage a patient’s drug therapy. Some pharmacists have developed trust-based relationships with certain physicians, and they work together on many different issues—especially when the physicians have patients with special needs, such as diabetes or asthma, and the pharmacists can work with them to help manage the patient’s drug therapy. Again, in 30 other states, physicians and pharmacists can work together and pharmacists are allowed to make medication adjustments as determined by a protocol, and then inform the physicians of changes. We believe that Connecticut law should be changed to follow this policy. Apparently, the Connecticut Department of Consumer Protection, the regulatory agency that oversees pharmacies, is concerned that, given the explosion of prescriptions and the shortage of pharmacists, medication error rates will escalate. Part of the rise in the number of medication errors is due to Q: A: Q: A: “Pharmacists go through six years of clinical education, which when combined with their access to patients, enable them to play an important role in patient care.” the fact that pharmacists are not able to spend the time needed with patients. Churning out a high volume of prescriptions can be dangerous, especially when dispensing powerful medications. The Institute of Medicine’s report on medical errors, To Err Is Human, documents that pharmacist interventions reduce errors and improve patient outcomes. Given the prescription volumes predicted for the near future, prescription error is a concern. In the past few years, questions about which medications should be listed on formularies and which ones should be omitted have increased. How do pharmacists negotiate this tension? A significant portion of the time pharmacists must spend dealing with insurance issues has to do with formulary maintenance. If a particular plan will not pay for a particular brand name drug, the prescription has to change to either a generic or another brand name drug. The brand-to-generic issue is becoming more widely accepted by the public. Patients need to become more cognizant of what medications their plan covers. However, the changes that occur when a patient has been successful on one medication and has to be switched to another because of a change in coverage are frustrating to the patient, the pharmacist, and the physician. The public is purchasing more herbal supplements and alternative medicines. What is the role of the pharmacists in mediating that situation? Many pharmacists are becoming more educated on herbal Q: and alternative medicines and keeping up to date on interactions. Unfortunately, we do not know all of the pills that our patients take because we cannot control the medications they get from other pharmacies or from mail order companies, and we certainly cannot control the herbals they purchase over the counter. At a minimum, we stress that it is best to centralize purchases from one pharmacy so that potential interactions can be caught. But because there is no real regulation of herbal products and alternative medicine, offering advice on these supplements is challenging. What are some of the complexities pharmacists face when dealing with older patients, who often take many different medications? We can give seniors all of the medications they need, but if they do not know how to take them safely, we will have a chaotic and dangerous situation. In the absence of guidance and education, adverse events will occur frequently. That is why on a national level, pharmacy groups are promoting a pharmacy benefit rather than a drug benefit. The drug benefit President Bush has suggested simply gets patients their drugs through a discount. But the discount will not really help seniors, who need real coverage not discounts. If they cannot afford a medication for $100, chances are they will not be able to afford one for $80 either. A: —Edited by Deborah J. Neveleff, in North Potomac, Md. More information on pharmacy strategies is available on our Web site (at www.qualityindicator.com). Q: A: Q: A: The Quality Indicator, Pharmacy Resource/November 2001 15 QualityIndicator.com Our FREE online resource includes: Now Available Online! Search our complete database by keyword, subject, or issue ARCHIVED ISSUES Review the top quality-of-care news stories of the week NEWSLINE View the latest issue of The Quality Indicator Interact with experts on all aspects of health care quality Find links to other quality of care resources CURRENT ISSUE ASK OUR EXPERTS RELEVANT LINKS Bookmark www. qualityindicator.com to your Internet favorites T H E N E W S L E T T E R O F Q U A L I T Y I S S U E S I N H E A LT H C A R E QualityIndicator The November 2001 PHARMACY RESOURCE Premier Healthcare Resource Suite 300, 99 Cherry Hill Road Parsippany, NJ 07054 PRSRT STD U.S. POSTAGE PA I D S.Hackensack, NJ Permit No 664
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