Strategies to optimize medication use in the physician group practice: the role of the clinical pharmacist.

OBJECTIVES: To (1) describe the role of clinical pharmacists in providing population-based pharmaceutical care as employees of a physician group practice, (2) describe the strategies used by pharmacists to optimize medication use, (3) quantify improvements in care, and (4) illustrate the calculations used to quantify cost savings. SETTING: Community-based, multispecialty, physician group practice located in the north Puget Sound area between 2003 and 2007. PRACTICE DESCRIPTION: Using four cornerstones (evidence-based medicine, therapeutic interchange, academic detailing, and a local pharmacy and therapeutics committee), the pharmacists provided population-based pharmaceutical care, leading generic switches, target drug programs, and prescription to over-the-counter medication switches. They also led disease management programs, managed drug recalls, implemented electronic health records, negotiated budgets with health plans, and led patient assistance programs and prior authorization programs to improve patient satisfaction. PRACTICE INNOVATION: Implementing these strategies from the vantage point of a physician group presents a seldom-realized employment opportunity for pharmacists. MAIN OUTCOME MEASURES: The impact of these strategies is measured by process, use, and clinical outcomes metrics. These, in turn, are linked to incentive payments in the pay-for-performance environment or to a lowered per member, per month cost in the capitated environment. RESULTS: In 2006-2007, 71% of our hypertensive patients received generic agents compared with a network average for receiving generic agents of 43%, while the proportion of patients with controlled blood pressure increased from 45% to 60%. We saved $450,000 in inpatient costs for deep venous thrombosis. CONCLUSION: Clinical pharmacists employed in a physician group practice can optimize medication use, improve care, and reduce costs.

A pharmacy leadership action study.

OBJECTIVES: To report on the creation of a leadership development program targeted exclusively at pharmacists working in management in the professional community. SETTING: Large staff-model health maintenance organization (HMO) in California between 2004 and 2008. PRACTICE DESCRIPTION: The Pharmacy Leadership Institute (PLI; a joint effort of the School of Pharmacy and the Center for the Health Professions at the University of California, San Francisco) tested a program in a large staff-model HMO with hundreds of pharmacists in leadership roles. This program included learning seminars, psychometric assessments, leadership goals, intersession activities, coaching/mentoring, and leadership projects. PRACTICE INNOVATION: Not applicable. MAIN OUTCOME MEASURES: PLI collected survey data in order to evaluate the effectiveness of the institute's leadership development program. In addition, an external evaluator was hired to conduct interviews with the pharmacy directors of the organization which chose to pilot the program. RESULTS: The evaluations from the participants indicate that the leadership development program met many but not all of its initial objectives. Consistent with action research methodology, the faculty of the institute met to redesign some sections of the program in order to meet the established goals. Adjustments were made to different components of the program over the next 4 years. Evaluation data show that these revisions were successful. In addition, follow-up evaluations with participants showed a lasting impact of the program on both individual leadership skills and organizational outcomes. CONCLUSION: Given the positive outcomes indicated by the evaluation data used in this study, the work of PLI indicates that broader leadership skills can be identified and enhanced within a group of pharmacy managers.

Computer-generated automatic alerts of respiratory distress after blood transfusion.

Transfusion-related acute lung injury (TRALI), the leading cause of transfusion-related death, is underreported by clinicians. For TRALI research, a clinician-independent, computerized system has been developed to detect patients with acute respiratory distress posttransfusion. A computer system generates an alert when a blood gas result indicated a PaO2:FiO2 ratio below 300, within twelve hours of blood issued from the blood bank for a patient. The system was prospectively compared to conventional daily rounds in intensive care units (ICUs). We found that ICU rounds detected 9 of 14 patients (64%), while the computer system detected 13 of 14 patients (93%), p = 0.125. ICU rounds took two to three hours per day, while the computer system took one to one and one-half hours per day of investigator time. In conclusion, an automatic computer alert system was more efficient, and was as effective as conventional daily ICU rounds, in detecting patients with posttransfusion acute respiratory distress.

Impact of a collaborative care model on depression in a primary care setting: a randomized controlled trial.

To measure the effects of a collaborative care model that emphasized the role of clinical pharmacists in providing drug therapy management and treatment follow-up to patients with depression, we conducted a randomized controlled trial at a staff model health maintenance organization. We compared the outcomes of subjects treated in this collaborative care model (75 patients, intervention group) with subjects receiving usual care (50 patients, control group). After 6 months, the intervention group demonstrated a significantly higher drug adherence rate than that of the control group (67% vs 48%, odds ratio 2.17, 95% confidence interval 1.04-4.51, p=0.038). Patient satisfaction was significantly greater among members randomly assigned to pharmacists' services than among controls, and provider satisfaction surveys revealed high approval rates as well. Changes in resource utilization were favorable for the intervention group, but differences from the control group did not achieve statistical significance. Clinical improvement was noted in both groups, but the difference was not significant. Clinical pharmacists had a favorable effect on multiple aspects of patient care. Future studies of this model in other health care settings appear warranted.

Impact of a collaborative pharmacy practice model on the treatment of depression in primary care.

The effects of a collaborative pharmacy practice model, in which clinical pharmacy specialists provided medication maintenance and follow-up patient care services at a clinic, on patients' adherence to treatment and satisfaction and costs were studied. A cohort of 13 primary care providers (PCPs) was designated to refer patients diagnosed with depression to the practice model at a staff-model health maintenance organization (HMO) immediately after the initiation of antidepressant medications. Clinical pharmacy specialists proceeded to coordinate follow-up with the patients for six months through a combination of scheduled office visits and telephone calls. Working closely with psychiatric liaisons, pharmacists were granted limited prescribing privileges to provide medication comanagement. These patients' adherence to treatment and satisfaction and costs to the HMO were compared with a control group of patients being treated for depression by the remaining 17 PCPs at the facility. A total of 91 patients were referred to the intervention group and received care from the pharmacists during the 10-month enrollment phase; 129 patients were included in the control group. There were no significant differences between groups regarding age, sex and chronic disease scores. An intent-to-treat analysis of medication adherence revealed that adherence was significantly higher in the intervention group (medication possession ratio, 0.81 versus 0.66) (p = 0.0005). Medication switch rates were higher among intervention patients as well (24% versus 5%) (p = 0.0001). There was a greater decline in the number of visits to PCPs for patients in the intervention group (39% versus 12%) (p = 0.029). A collaborative practice model in which clinical pharmacy specialists managed the medication therapy of patients with mild to moderate depression increased patients' adherence to treatment and their satisfaction and reduced the patients' subsequent visits to PCPs.