Pharmacists go beyond the counter to aid inpatients

A University of Iowa/Department of Veterans Affairs review of previously published studies found that getting hospital-based pharmacists out from behind the counter to work directly with inpatients and health care teams reduced medication errors and problems.

Researchers said the change in pharmacists' roles also helped patients understand and follow their drug regimes. Previously, they said, pharmacists often did not see hospitalized patients firsthand, but in the last 20 years, they have become more involved in collaborative patient care.

"Pharmacists play an important role in caring for hospitalized patients in terms of medication safety and helping determine that patients are on the most appropriate medications," said Peter Kaboli, MD, an investigator with the Center for Research in the Implementation of Innovative Strategies at the Veterans Affairs Iowa City Health Care System and assistant professor of internal medicine at the University of Iowa College of Medicine, who led the review study. "Hospitals and health systems are seeing the value of putting pharmacists in daily contact with patients and having the pharmacists interact with other health care providers daily."

Kaboli and his colleagues analyzed 36 studies published between 1985 and 2005 in English-language peer-reviewed journals. Their review appeared in the Archives of Internal Medicine.

According to Kaboli, two Institute of Medicine reports recognized that pharmacists are an essential resource in safe medication use, that participation of pharmacists on rounds improves medication safety, and that pharmacist-physician-patient collaboration is important.

He said the role of clinical pharmacists differs from that of traditional pharmacists in that the clinical pharmacists work directly with providers and patients to provide services not simply associated with dispensing drugs. Many clinical pharmacists have completed residencies and are board certified in specialty areas such as pharmacotherapy, oncology, nutrition, and psychiatry, he added.

Kaboli said his review of the 36 studies "supports the use of clinical pharmacists in the inpatient setting to improve the quality, safety, and efficiency of care." He noted the Institute of Medicine report Crossing the Quality Chasm suggested that clinical pharmacists have a significant role in addressing quality issues in hospitalized patients, and the Joint Commission on the Accreditation of Healthcare Organizations mandates medication reconciliation at the time of hospital admission and discharge. By further developing collaborative care, he said, the clinical pharmacist can be an integral part of the inpatient care team.

Interventions hard if there is a cost

He noted that implementing new hospital programs is difficult, especially if they require allocation of new resources. Thus, one fundamental advantage to the pharmacist interventions considered is that most can be implemented through reallocation of existing resources to increase clinical pharmacist services. Published studies evaluating the cost of incorporating clinical pharmacists have generally demonstrated a net hospital cost benefit in terms of cost avoidance and use, he said. And in some settings, new pharmacy positions such as technicians have been created to fill expanded clinical roles and pharmacist duties have been reorganized to enable more direct interactions with patients and physicians on rounds.

"More research is needed to better understand the role of clinical pharmacists, clinical areas most likely to benefit, and patient-specific factors associated with improvements," Kaboli wrote. "Cost-effectiveness can also be improved by identifying pharmacist duties most beneficial to patients and determining whether less skilled and costly personnel can perform other duties." He said future studies should describe interventions in enough detail that they can be reproduced, and outcomes such as medication appropriateness and adherence should be measured using validated instruments.

Earlier studies of pharmacy care in hospitals, Kaboli said, usually focused on specific drugs such as blood thinners, or specific diseases. "That's important," he said, "but it's also important to look at the bigger picture." His review of the studies analyzed point to a systems approach and how pharmacists care for inpatients by meeting with them at admittance, visiting during rounds, and meeting again at discharge.

At both the University of Iowa Hospitals and Clinics and within the VA Health Care System, pharmacists play a critical role in managing disease for inpatients, he says, and it is not only about delivering drugs, but also information.

Over the past several decades, the number of medications and the complexity of drug therapy have grown enormously, according to University of Iowa Hospitals and Clinics director of pharmaceutical care Paul Abramowitz, who is responsible for the work of some 90 pharmacists providing clinical care. "Pharmacists focus on all aspects of the patient's drug therapy," he says. "They work with the patient, physician, and nurse to help maximize the benefits and outcomes of medications and to minimize adverse effects. This also includes a significant amount of attention to medication safety every step in the medication use process."

Medication reconciliation mandated

As part of a patient's hospital stay, the Joint Commission on Accreditation of Healthcare Organizations mandates a "medication reconciliation" in which providers review with the patient the drugs taken from admission through discharge to ensure appropriateness. The reconciliation also helps patients understand costs, conveniences, and other factors that might affect a medication's intended use.

For patients with dementia, health illiteracy, or other problems that could affect use of medications, the pharmacist also can meet with family members or other helpers for medication planning.

Carl Hensley II, the pharmacy benefits manager for VA hospitals in Veterans Integrated Service Network 23, which covers five states including Iowa, says pharmacists' efforts help cut costs and improve patients' quality of life.

"Patients are more satisfied if they have more contact with a pharmacist or at least are given the opportunity to do so," he says. "For example, they can better understand what might happen if they miss a dose or why they need to take a medication even if it has a short-term negative side effect."

And some of the studies reviewed indicated greater job satisfaction for pharmacists who interact more with patients and physicians, Kaboli said.

Kaboli's team is now working on a study looking at outpatient care and pharmacist-physician team interventions.

(Editor's note: More information is available from University of Iowa Health Sciences Relations in Iowa City, IA. A study abstract is available on-line at www.archinternmed.com. The full study is available there for subscribers. Contact Dr. Kaboli by e-mail at peter-kaboli@uiowa.edu.)