The perceived influence of clinical pharmacy services on physician prescribing behavior: a matched-pair comparison of pharmacists and physicians

In contrast with cross-sectional designs used in previous studies, this exploratory study compared survey data from 127 matched pairs of clinical pharmacists and physicians working together. Physicians' perceptions of the importance of clinical pharmacy activities for patient care and the competence of pharmacists performing the activities were examined for their influence on prescribing behavior in an institutional setting. Data from a national survey showed that physicians rated pharmacists higher regarding recommendations based on drug use evaluations (p = 0.004) and competency to provide all clinical pharmacy services. Scores for pharmacokinetics ratings were similar between pharmacists and physicians (p = 0.168). Pharmacists rated the importance of recommendations based on cost-effectiveness higher than physicians (p = 0.012). Overall, physicians' perceptions of activity importance for patient care and pharmacist competency appear to dictate pharmacists' influence on physician prescribing behavior (R = 0.723).     

The compatibility of the retail setting with a patient-based practice model: reports from community pharmacists

The patient counselling and prospective drug utilization review mandates of the Omnibus Budget Reconciliation Act of 1990 raise the question of how compatible the retail pharmacy setting in the United States is with a patient-based model of pharmacy practice. In order to investigate this question, a self-administered questionnaire was distributed by pharmacy students to a convenience sample of pharmacists with at least one year's experience in the community setting. The questionnaire asks respondents to recall two incidents: one that caused them to gain or retain a patient or that was for some reason a source of professional satisfaction, and one that may have caused the loss of a patient or that they would handle differently if faced with the situation or problem again. The respondents practice in pharmacies in and around a large midwestern city. Data analysis showed that respondents tend to identify patient-based activities when recalling appropriate behaviours and traditional or customer-based activities when recalling inappropriate behaviours or mistakes. Patient-based activities can sometimes result in the loss of business, but they can also result in patronage gains, especially when performed in conjunction with good customer service. In summary, these pharmacists do implement a patient-based model in some situations. The patient-based and customer-based models can be complementary in that the patient can benefit from the services of an expert health professional while simultaneously being treated with the respect and 'customer knows best' attitudes indicative of the retail setting.     

Recombinant alpha2-interferon substances in treating patients with acute hepatitis B with a mild course]

The role of clinical pharmacy in the health care system is changing rapidly. This change is almost universal among different countries and is related to developments in medical technology, health economics, informatics, socio-economic status, and professional relations. Transitions to new systems of clinical pharmacy are difficult to anticipate. Even with well defined targets, it remains uncertain what the future of clinical pharmacy will bring us. The construction of plausible scenarios may help us better in preparing for the 'new world' ahead. At the annual congresses of ESCP in Prague 1995 (24th) and Lisbon 1996 (25th), a number of scenario analysis workshops with respect to the future of clinical pharmacy were organized. This paper gives a report of the results of these scenario sessions and reflects on the implications for future policy making. After we identified the driving forces behind the future of clinical pharmacy, various sets of assumptions were made and from them scenarios were constructed which are plausible: they 'could' happen. This analysis provided a logical framework in which we ultimately depicted three alternating stories of the future of clinical pharmacy, named 'CLERK', 'CONTROLLER' and 'CARE MANAGER'. These scenarios are intended to help clinical pharmacists to break free of familiar mental maps and to stimulate creative thinking on the future.     

Accuracy of technicians versus pharmacists in checking syringes prepared for a dialysis program

The accuracy of pharmacy technicians versus pharmacists in checking drug doses prepared in syringes for a dialysis program was studied. Three pharmacy technicians from the pharmacy of a regional kidney disease program in Minnesota participated in the study after completing a training program and after common preparation errors had been identified by pharmacists. From November 1995 to April 1996, the technicians used labels printed from a database of pharmacist-verified orders to prepare and label i.v. syringes. Four medications were used-epoetin alfa, calcitriol, heparin prepared from beef lung, and heparin prepared from porcine intestinal mucosa. Each syringe was checked by one of nine pharmacists for accuracy of dose and medication, and all errors were recorded. The technicians checked syringes prepared by other technicians and also recorded errors. Accuracy rates (percentages of syringes correctly evaluated) for pharmacists and technicians were compared. A total of 10,608 syringes were checked. Accuracy rates for pharmacists and pharmacy technicians were 99.86% and 99.83%, respectively. Accuracy rates in checking syringes did not differ significantly between pharmacists and technicians in this study setting.     

Implementing disease management in community pharmacy practice

Disease management (DM) is a comprehensive approach to preventing and treating disease that: (1) targets patients with specific diseases; (2) provides integrated services across organizational and professional boundaries; (3) utilizes services based on the best scientific evidence available; and (4) focuses on outcomes. DM differs from pharmaceutical care in that pharmaceutical care targets not only patients with specific diseases but also those with risk factors for drug-related problems, a history of nonadherence, and frequent changes in medication regimens. Steps to starting a DM program include: (1) identifying a target population based on the population's strategic importance to the goals and aims of the organization; (2) assessing the organization's available resources, both internal and external; (3) defining key indicators with which to assess the program for the purposes of internal quality control and of obtaining compensation from third-party payers; (4) implementing the program using the best scientific methods available; and (5) assessing the impact of the program. The development of a smoking cessation program at a nationwide retail pharmacy chain is used as an example of a DM program initiated in community pharmacy practice. Pharmacists are well positioned to take a major role in DM, because they are accessible to the community and because DM frequently involves drug therapy. DM is also widely used in managed care. It is important that community pharmacists be closely involved in the DM approach as it evolves.     

Cancer vaccines. Part 2

Cancer vaccines are being widely studied for the purpose of immune modulation and subsequent antitumor effects. This article cites only a few examples of the many studies underway. Many vaccines have shown efficacy in eliciting systemic responses with minimal toxicities. The use of vaccines as a modality of cancer therapy in combination with chemotherapy, surgery, and radiation therapy is also being investigated. Although the routine use of approved vaccines is still a goal for the future, instituting this fourth modality of cancer therapy is not too distant. Phase III trials with both melanoma and colon cancer vaccines have been completed. Synthetic carbohydrate antigen vaccines have shown efficacy in several tumor types during Phase II trials and are also generating enthusiasm. The potential impact of vaccine therapy on the profession of pharmacy may involve patient counseling regarding management of side effects and possibly also dispensing of vaccine therapy products to patients directly for home administration. As ambulatory sites open in conjunction with pharmacy services and pharmacists obtain prescribing authority, pharmacists' active involvement in vaccine counseling and administration seems likely.     

Hospital drug supply around the turn of the century--the founding of the pharmacy at the city hospital of Worms]

Around the turn of the century drug supply of the civil hospital in Worms was carried out by local pharmacists, drug distribution and preparation of simple solutions by a nurse. The municipal authorities which were responsible for the hospital were sure that the establishment of a pharmacy in the hospital itself could improve drug supply. The study shows how the authorities went through with the opening of a hospital pharmacy despite the expected opposition of the local pharmacists and that such an establishment and the employment of a pharmacist were profitable even for a hospital with only 200 beds.     

Serum LH concentrations in hypogonadal men during transdermal testosterone replacement through scrotal skin: further evidence that ageing enhances testosterone negative feedback. The Testoderm Study Group

As a trial of the provision of community-service information to family carers, general practitioners and pharmacists from the Western region of Melbourne were supplied with tear-off pads listing suburb-specific community services, and were encouraged to discuss service needs with carers of people with disabilities and distribute the lists to carers accordingly. One hundred and nine general practitioners and 58 pharmacists participated in pretrial and post-trial interviews assessing their knowledge of community services and frequency of discussion with carers. Before the trial, general practitioners had significantly higher self-rated knowledge of community services and reportedly discussed these with carers more often than did pharmacists. After the five-month trial period, pharmacists showed a significant increase in self-rated knowledge and frequency of discussion. General practitioners' knowledge and discussion showed a nonsignificant increase. After the trial, the two did not differ in knowledge of services; however, general practitioners maintained a higher reported frequency of discussion about services with carers. General practitioners and pharmacists appear to be well placed to act as a service link for family carers. However, additional high-intensity strategies are needed to assist them in this role.     

Sources of regulatory information for pharmacists

Sources of regulatory information of use to pharmacists are summarized. Regulatory information is provided by government, legal, pharmaceutical industry, nongovernment, and investigational drug sources. Databases and trade and professional organizations also provide such information. Information on legislative statutes and regulations can be found in the Federal Register, Code of Federal Regulations, and List of CFR Sections Affected. Many other government reports are also available. Various law reports are published by state and federal courts; legal textbooks, journals, and newsletters also provide pharmacy law information. Pharmaceutical industry sources supply information on U.S. drug approvals, pharmaceutical companies, and FDA enforcement actions, whereas nongovernment regulatory sources provide comprehensive regulatory and drug information. Investigational drug sources enable pharmacists to keep abreast of new drug development. Databases provide a wide variety of information, and trade newsletters supply information of interest to the organization. Knowledge of appropriate references will allow pharmacists to keep abreast of regulations that may affect them and new developments in their area of expertise.     

Third-party reimbursement for clinical pharmacy services: philosophy and practice

A step-by-step approach is outlined for obtaining third-party reimbursement for clinical pharmacy services separate from dispensing fees. The program is based on a patient-care philosophy rather than a cost-conscious philosophy. The steps in implementation of the program were: (1) a total commitment to the patient's health, (2) identification of patient needs that require clinical pharmacy expertise, (3) development of a patient training program, (4) presentation of a written proposal to the hospital administration, (5) presentation of the proposal to third-party agencies, (6) initiation of charges for the services, and (7) preparation of reports on the progress of the program. Third-party reimbursement covers pharmacist instruction of home therapy patients receiving antihemophilic factor, cytarabine, parenteral nutrition, calcitonin-salmon and injectable analgesics. Financial data based on one year's experience with the program show that savings far outweight the charges.     

Humanistic outcomes in the hypertension and COPD arms of a multicenter outcomes study

OBJECTIVE: To evaluate the effects of pharmaceutical care on selected humanistic outcomes in patients with hypertension or chronic obstructive pulmonary disease (COPD). DESIGN: Clinic patients with hypertension or COPD were randomly assigned to a treatment group (pharmaceutical care) or a control group (traditional pharmacy care) over a six-month period. Clinical pharmacists and pharmacy residents conducted the protocols. There were 133 evaluable patients (63 treatment, 70 control) in the hypertension study arm and 98 evaluable patients (43 treatment, 55 control) in the COPD study arm. The Pharmaceutical Care Questionnaire evaluated patient satisfaction with care. Tests specific to the disease states assessed disease and disease management knowledge. Quality of life (QOL) was evaluated using the Health Status Questionnaire 2.0 (HSQ 2.0) in the COPD arm; in the hypertension arm, the Hypertension/Lipid TyPE Specification Form 5.1 was used. SETTING: Ambulatory care centers of 10 Department of Veterans Affairs (DVA) medical centers and 1 university medical center. INTERVENTIONS: Patient-centered pharmaceutical care model (employing standardized care) implemented by clinical pharmacy residents. MAIN OUTCOME MEASURES: Satisfaction with pharmaceutical care, disease and disease management knowledge, and QOL. RESULTS: Statistically significant differences in most satisfaction items were found, with treatment patients expressing greater satisfaction. Treatment groups in both arms strongly agreed that pharmacists helped them with confidence in use of their medication and understanding of their illness, gave complete explanations about their medications, made them feel that their care was a priority, and followed up on their questions and concerns. In the hypertension arm, treatment patients demonstrated significant increases in knowledge scores. Trends in QOL were positive for both hypertension groups, with a significant decrease found in number of treatment patients reporting problems with sexual function. In the COPD arm, improvement trends were significantly stronger for treatment patients. CONCLUSION: Although patients were not dissatisfied with traditional pharmacy care, they were more satisfied overall with the pharmaceutical care model.     

Clinical pharmacy services in hospitals educating pharmacy students

In 1995 we conducted a national survey of 1102 acute care hospitals in the United States to determine types of clinical pharmacy services, patient-focused care, and pharmaceutical care used to educate and train pharmacy students, and compared outcomes with surveys in 1989 and 1992. Clinical pharmacy services offered in 50% or more of Pharm.D.-affiliated hospitals (core services) were drug-use evaluation, in-service education, pharmacokinetic consultations, adverse drug reaction management, drug therapy monitoring, protocol management (most common for aminoglycosides, nutrition, antibiotics, heparin, warfarin, theophylline), nutrition team, and drug counseling. Comprehensive pharmaceutical care programs were established in 64%, 42%, and 33% of Pharm.D., B.S., and nonteaching hospitals, respectively. Patient-focused care programs were beginning or established in 77%, 71%, and 60%, respectively. Pharmacists served as care team leaders in 23% of hospitals affiliated with a college of pharmacy. Most common ambulatory care clinics were oncology, anticoagulation, diabetes, geriatrics, refill, and infectious diseases/HIV. For-profit hospitals rarely provided education for pharmacy students. Thus patient-focused and comprehensive pharmaceutical care programs exist according to a hospital's academic program affiliation with Pharm.D. or B.S. degree program.     

Billing third party payers for pharmaceutical care services

OBJECTIVE: To describe the steps pharmacists must complete when seeking compensation from third party payers for pharmaceutical care services. DATA SOURCES: Government publications; professional publications, including manuals and newsletters; authors' personal experience. DATA SYNTHESIS: Pharmacists in increasing numbers are meeting with success in getting reimbursed by third party payers for patient care activities. However, many pharmacists remain reluctant to seek compensation because they do not understand the steps involved. Preparatory steps include obtaining a provider/supplier number, procuring appropriate claim forms, developing data collection and documentation systems, establishing professional fees, creating a marketing plan, and developing an accounting system. To bill for specific patient care services, pharmacists need to collect the patient's insurance information, obtain a statement of medical necessity from the patient's physician, complete the appropriate claim form accurately, and submit the claim with supporting documentation to the insurer. Although many claims from pharmacists are rejected initially, pharmacists who work with third party payers to understand the reasons for denial of payment often receive compensation when claims are resubmitted. CONCLUSION: Pharmacists who follow these guidelines for billing third party payers for pharmaceutical care services should notice an increase in the number of paid claims.