Transcript Diapositive 1 - Lillyhospitalsurvey

Hospital Pharmacy in Canada
2005-2006
Hey Kid …
what do you do now ?
Jean-François Bussières
B Pharm MSc MBA FCSHP
Chef, département de pharmacie et unité de recherche en pratique
pharmaceutique
Professeur agrégé de clinique
Faculté de pharmacie, Université de Montréal
Membre du comité de rédaction
Rapport canadien sur la pharmacie hospitalière
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 ?
Who are we ?
• Response rate = 74 %
• Teaching institutions = 26 %
Johnson N et al. Hospital Pharmacy in Canada 2005-6
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
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 welldefined 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
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
Clinical practice models
• Pharmaceutical care AND absence of
clinical services have progressed over the
last 10 year-period
Practice models
100%
Proportion of respondants (%)
90%
80%
70%
60%
Pharmaceutical care model
50%
Traditional clinical services
No clinical services
40%
30%
20%
10%
0%
1996-1997
1997-1998
1999-2000
Fiscal years
2001-2002
2005-2006
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
70%
Proportion of respondants (%)
60%
50%
40%
% of beds covered - PC
% of beds covered - TCS
30%
% of beds Uncovered - None
20%
10%
0%
1996-1997
1997-1998
1999-2000
Fiscal years
2001-2002
2005-2006
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
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
A new entry-level Pharm. D.
Transversals
• Professionnalism
• Communication
• Team work and interdisciplinarity
• Scientifical reasoning and critical thinking
• Autonomy in learning
• Leadership
Specifics
• Pharmaceutical care
• Service to the community
• Pharmacy management and operations
A new entry-level Pharm. D.
A new entry-level Pharm. D.
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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
Staffing
• There are different ratios that can be used to
compare pharmacy staffing to others e.g. doses
dispensed/y, case-mix index-ajusted patientdays, admission, occupied beds etc.
Gupta SR et coll. AJHP 2007; 64: 937-44.
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.
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
Staffing
Johnson N et al. Hospital Pharmacy in Canada 2005-6
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
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
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.
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
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 ?)
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
Specialization
Outpatient 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
Specialization
Outpatient pharmacy services
Johnson N et al. Hospital Pharmacy in Canada 2005-6
Specialization
Inpatient pharmacy services
Johnson N et al. Hospital Pharmacy in Canada 2005-6
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
Effectiveness of hospital pharmacy
• 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
Guild of healthcare pharmacists. 2001
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
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
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
Economic benefits
Economic benefits
Effect of pharmacists’ interventions on patient
and process outcomes
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
Association between pharmacists, clinical
pharmacy and health care outcomes
• 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
Bond CA et al. Pharmacotherapy 2001; 21 (2): 129-41.
Association between pharmacists, clinical
pharmacy and health care outcomes
• Increasing # clinical pharmacists is associated with a reduction in
LOS
Bond CA et al. Pharmacotherapy 2001; 21 (2): 129-41.
Association between pharmacists, clinical
pharmacy and health care outcomes
 50 % des
ADR/year by
increasing the #
clinical
pharmacists/100
occupied beds
from 0,9 à 5,7
Bond CA et al. Pharmacotherapy 2006; 26 (6); 735-47
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)
BEFORE
Prioritization
Admission and discharge interviews
80%
Clinical activities w ith patients
Proportion of respondants (%)
70%
60%
50%
40%
30%
20%
10%
0%
1986- 1987- 1989- 1990- 1991- 1992- 1993- 1994- 1995- 1996- 1997- 1999- 20011987 1988 1990 1991 1992 1993 1994 1995 1996 1997 1998 2000 2002
Fiscal years
Admission int erviews
Discharge int erviews
Prioritization - Rounds and consultation with
physicians and kardex rounds with nurses
Prioritization
Pharmacokinetic dosings
Grow th of PK dosing
90%
80%
70%
60%
P r opor t i on of r e sponda nt s
of f e r i ng P K D
50%
40%
Pharmacokinet ic dosing nd
30%
20%
10%
0%
1986-
1987-
1989-
1990-
1991-
1992-
1993-
1994-
1995-
1996-
1997-
1999-
2001-
1987
1988
1990
1991
1992
1993
1994
1995
1996
1997
1998
2000
2002
Fi sc a l y e a r s
AFTER
Average level of service and
ranking priority
Johnson N et al. Hospital Pharmacy in Canada 2005-6
Average level of service and
ranking priority
Johnson N et al. Hospital Pharmacy in Canada 2005-6
Prescribing
Evaluation
Johnson N et al. Hospital Pharmacy in Canada 2005-6
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
2015 Vision
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