Outcome-focused counseling program for quality assurance in ambulatory care.

An outcome-focused patient-counseling program designed to enhance quality assurance in ambulatory pharmaceutical care is described. Drugs for which counseling was mandatory because of their potential for association with an adverse outcome were listed. A checklist was created for each drug class to assist pharmacists in providing uniform information and to serve as a follow-up document for quality assurance. The completed forms are used to indicate which patients' charts should be pulled for review against quality assurance criteria for the monitored drug classes; the criteria function as indicators of an adverse outcome. Findings are summarized and presented at the monthly meeting of the departmental quality assurance committee. The program was phased in one drug class at a time. Between October 1988 and January 1989, 18 charts were reviewed for the two drug classes being monitored during that period. There were no patients to whom the indicators of an adverse outcome applied. The outpatient-counseling program helped pharmacists to provide consistent information and to focus on those drugs with the highest potential for adverse outcomes. Incorporating the program into quality assurance activities made it easier to measure patient outcomes.

Indicators for the selection of ambulatory patients who warrant pharmacist monitoring.

The development of indicators to identify ambulatory patients who might benefit from pharmacist monitoring is described. With the assistance of an eight-member panel of ambulatory-care pharmacists, six prognostic indicators were identified: (1) five or more medications in present drug regimen, (2) 12 or more medication doses per day, (3) medication regimen changed four or more times during the past 12 months, (4) more than three concurrent disease states present, (5) history of noncompliance, and (6) presence of drugs that require therapeutic drug monitoring. The charts of patients who had visited the internal medicine, general surgery, pediatric, and obstetric/gynecology clinics during five randomly selected weeks in 1985 and 1986 were reviewed to determine the presence or absence of the six prognostic indicators and their adverse outcomes. Evidence of drug-therapy-related adverse outcomes was present in 79 (33.1%) of 239 charts. Charts of patients with a documented history of noncompliance were most likely to show evidence of an adverse outcome. The likelihood that a patient chart would show evidence of an adverse outcome increased as the number of prognostic indicators present increased. The presence of individual or multiple prognostic indicators in the charts of ambulatory-care patients should enable pharmacists to identify patients at greatest risk of experiencing drug-therapy-related adverse outcomes.