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T H E N E W S L E T T E R O F Q U A L I T Y I S S U E S I N H E A LT H C A R E
The
QualityIndicator
November 2001
PHARMACY RESOURCE
Pharmacists, Technicians Show
How To Improve Patient Care
F
aced with a burgeoning workload and a continuously increasing number of prescriptions to be
filled, more pharmacists are asking pharmacy technicians to help them manage pharmacy care,
experts say. A report on a survey conducted last year by the National Association of Boards of
Pharmacy (NABP), in Park Ridge, Ill., concluded what many in the pharmacy profession suspected
but could not prove: Under proper supervision, pharmacy technicians improve pharmacy services.
To recognize pharmacy technicians’
roles, and the effectiveness of the collaboration between pharmacists and
pharmacy technicians in advancing
patient
care,
the
Pharmacy
Technician Certification Board
(PTCB), in Washington, D.C., and
Baxter Healthcare Corp., a medical
products and services company in
Deerfield, Ill., founded the annual
“Innovations in Pharmaceutical Care
Awards” in 1998. The awards recognize excellence in leadership and
innovation in working to improve
patient care, says Melissa Murer, RPh,
executive director of the PTCB. Since
it was founded in 1995, PTCB has certified more than 86,000 pharmacy
technicians (CPhTs).
The most recent award winners represent a variety of practice settings.
They are the Veterans Administration
CONTENTS
Editorial
Two Groups Vie to Develop E-Systems
2
Strategy
Beta-Blocker Program Helps Cut Costs, Improve
Quality of Care
3
Long-Term Care
Guidelines Stress Importance of Early Alzheimer’s Diagnosis
6
Disease Management
Studies Raise Concern About Weight,
Antipsychotic Medication
8
Interview
Pharmacists Seek to Address
Work Force Issues in Connecticut
13
Medical Center, Inpatient Care
Services, in Phoenix; Duke University
Medical Center, in Durham, N.C.;
and Zive Pharmacy & Surgical Inc., in
the Bronx, N.Y. Each program offers
lessons for managed care pharmacies
seeking to improve care.
VA Medical Center
The Veterans Administration Medical
Center, in Phoenix, is a 181-bed medical-surgical teaching hospital that
provides 48,000 bed days of care per
year. Seeking to spend more time with
patients, but lacking the time to do so,
the hospital’s inpatient clinical pharmacy team hired two clinical pharmacy technicians in October 1998, says
Ed Foltz, PharmD, the team’s manager. At the time, his team consisted of
six clinical pharmacists and two discharge pharmacists.
It wasn’t until his department had
an opening for a pharmacist that the
hiring of two pharmacy technicians
instead of a pharmacist was considered, Foltz explains. “Over the course
of a few months, we, as a team, listed
the responsibilities that we felt comfortable delegating to the technicians,” he says. “These responsibilities
(Continued on page 11)
EDITORIAL
Two Groups Vie to Develop E-Systems
T
here’s no denying that pharmacies need better, more sophisticated systems
to speed the process of receiving prescriptions and delivering medications.
And new systems are being developed to improve efficiency and reduce medication errors. But the issue managed care pharmacists face is which standards
will be developed.
This summer, the National Association of Chain Drug Stores (NACDS) and
the National Community Pharmacists Association (NCPA), both in
Alexandria, Va., formed SureScript Systems Inc., a new venture designed to
accelerate the adoption of an efficient, secure electronic system to connect prescribers and pharmacists directly. To be based in Northern Virginia, SureScript
will be officially launched later this year. The system will connect physicians’
offices to the largest possible number of pharmacies, and those pharmacies will
be able to communicate electronically with the affiliated physicians.
“For an electronic system to be truly valuable to prescribers, it needs to connect them to as many pharmacies in their local market as possible,” says Calvin
Anthony, executive vice president of NCPA and co-chairman of SureScript
Systems.
Electronic communications through SureScript Systems will maximize
health professionals’ time with patients, the organizations say. “With
SureScript, communications between a patient’s pharmacist and doctor will be
direct and without interference by any third party,” Anthony says.
Earlier this year, three pharmacy benefit managers (PBMs)—AdvancePCS,
in Irving, Texas; Express Scripts, in St. Louis; and Merck-Medco, in Franklin
Lakes, N.J.—formed RxHub LLC, to develop an electronic exchange system to
improve prescription safety, cut costs, and develop industry standards for transmitting prescriptions electronically. The three PBMs said the new system will
increase the accuracy and efficiency of prescription writing and dispensing,
increase safety for patients, and cut costs for employers and health plans. Also,
it will provide a standardized channel of communication to link physicians,
through electronic prescribing software on handheld computers or practice
management systems, to pharmacies, PBMs, and health plans. The nation’s
PBMs provide pharmacy services to more than 170 million Americans.
Both of these ventures aim to solve similar problems, but each wants to protect its own turf. The independent pharmacies do not want the PBMs to gain
any more leverage in the dispensing of medications; the PBMs want to ensure
that they are part of the solution to the problems currently plaguing the health
care system.
Organizers of both systems say others are welcome to join them. It will be
intriguing to see which organizations join which venture.
Joseph Burns, Editor
21 Stone Wall Lane
Falmouth MA 02540-2219
Phone: 508/495-0246
Fax: 508/495-0247
E-mail: jburns@premierhealthcare.com
2 The Quality Indicator, Pharmacy Resource/November 2001
ADVISORY BOARD
Maude A. Babington, PharmD
Partner
Babington Consulting, LLC
Boulder, Colo.
David Berenbeim, MD, MBA, FACP
Vice President and Medical Director
Prescription Solutions
Costa Mesa, Calif.
Judith A. Cahill, CEBS
Executive Director
Academy of Managed Care Pharmacy
Alexandria, Va.
Steven B. Cano, MS, FASHP
Director of Pharmacy
Fallon Healthcare System and
Saint Vincent Healthcare System
Worcester, Mass.
Robert M. Elenbaas, PharmD
Executive Director
American College of Clinical Pharmacy
Kansas City, Mo.
Donna W. Howell-Smith
Director, Clinical Pharmacy Programs
Humana Inc.
Louisville, Ky.
Peter Kwok, PharmD
Pharmacy Services Manager
Health Plan of the Redwoods
Santa Rosa, Calif.
Harlan Martin, RPh, CCP, FASCP
President
Pharma-Care Inc.
Clark, N.J.
Dennis M. Williams, PharmD
Chair, American Society of
Health System Pharmacists, Section
of Clinical Specialists
Assistant Professor, Division of
Pharmacotherapy
University of North Carolina
School of Pharmacy
Chapel Hill
The Quality Indicator, Pharmacy Resource, is
published by Premier Healthcare Resource, Inc.,
Parsippany, N.J.
© Copyright strictly reserved. This newsletter
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STRATEGY
Beta-Blocker Program Helps Cut
Costs, Improve Quality of Care
T
ypically, family physician Brian K. Solow, MD, of the Bristol Park Medical Group in
Irvine, Calif., is inundated with a steady stream of mail, mainly from HMOs or other managed care companies. Recognizing that much of it is junk, he reviews what appears useful
and tosses out the rest. One piece of mail recently caught his attention, however: a letter from
Prescription Solutions, a pharmacy benefit management company, reinforcing the fact that betablockers should be prescribed for post-myocardial infarction patients.
“Doctors don’t usually want other
people telling them how to run their
practices, but the letter from
Prescription Solutions provided useful information,” Solow recalls. In the
letter, the PBM said its Drug Regimen
Review Program was designed to
improve the quality of care for health
plan members who had had an acute
myocardial infarction (AMI). It also
listed the names of patients in Solow’s
practice who had been diagnosed
with an acute myocardial infarction,
but who did not have a record of having received a prescription for a betablocker, at least not through
Prescription Solutions.
Physician Education
Prescription Solutions, in Costa
Mesa, Calif., is a subsidiary of
PacifiCare Health Systems Inc. The
information that Solow received was
part of its Drug Regimen Review
Program that focused on the use of
beta-blockers after an AMI. The goals
of the program are to educate physicians working for PacifiCare on the
value and life-saving effect of the
treatment regime, to identify patients
suitable for the intervention, and to
promote the use of beta-blockers
among those patients who have had
heart attacks.
“As a pharmacy and medical management company, we recognize that
heart disease is one of the leading
causes of death among Americans,”
says David Berenbeim, MD, vice president of clinical services for
Prescription Solutions. Annually,
about 220,000 people die of heart
attacks without being hospitalized,
and about two thirds of those people
have had prior heart attacks, he
explains. Many deaths could be prevented if patients are properly diagnosed and treated properly, he adds.
Southern California (USC) School
of Pharmacy shows that the program
has produced significant results. “Our
evaluation provided evidence that
contacting providers increased the
likelihood by 40% that patients
would be initiated on beta-blocker
therapy,” says Michael B. Nichol,
PhD, associate professor and chair of
the USC pharmacy school. The
objective of the analysis was to esti-
“We initiated this program to educate doctors
on the benefits of beta-blocker therapy, and
our analysis shows that it saves significant
dollars for health plan sponsors.”
—David Berenbeim, MD, Prescription Solutions
Recognizing that beta-blockers are
effective in reducing the risk of a second heart attack in post-MI patients,
managers at Prescription Solutions
assumed that not all physicians
understood the value of beta-blockers
or when and how to prescribe them.
“We initiated this beta-blocker program to educate doctors on the benefits of beta-blocker therapy, and our
analysis shows that it saves significant
dollars for health plan sponsors,”
Berenbeim says. The program gives
physicians the data they need to
make better prescribing decisions,
ultimately saving lives, he explains.
An analysis of the program by
researchers at the University of
mate the economic effect of using
beta-blockers for AMI patients as a
long-term prophylaxis in the
PacifiCare population in California.
The USC study shows that 2,301
members of PacifiCare experienced
an AMI during the review period. Of
those members, 1,772 (77%) did not
have a contraindication to a betablocker. Of the 1,772 members, 927
(52%) received a beta-blocker and
846 (48%) did not. Following the
intervention, beta-blocker usage
increased in both the intervention
and control populations. The cost of
beta-blockers on a per member per
month (PMPM) basis in the intervention group increased from $0 to
(Continued on page 4)
The Quality Indicator, Pharmacy Resource/November 2001 3
STRATEGY
(Continued from page 3)
$1.40 by the 12th month following
the intervention. The cost of betablockers in the control population
remained at less than 20 cents
throughout the same period.
The intervention group was 1.4
times more likely to get a beta-blocker prescription after the intervention
date. AMI patients who had received
a beta-blocker at some point before
the intervention date were 2.5 times
more likely to receive a beta-blocker
after the intervention than members
who had no prior history of betablocker use.
The USC evaluation showed that
contacting providers increased the
likelihood that patients would be initiated on beta-blocker therapy,
Nichol comments. The program also
showed that it might be useful to target the intervention for patients who
had previously been initiated betablocker therapy, because that was an
excellent predictor of treatment success, Nichols says.
A QI Initiative
The American Heart Association
estimates that nearly 5 million people
have a heart attack each year. Studies
show that beta-blockers reduce stress
on the heart by decreasing its workload. In fact, recent studies in the
Journal of the American College of
Cardiology and the British Journal of
Medicine have underscored their value
in preventing second heart attacks.
Prescription Solutions developed
the beta-blocker program in 1999 as a
quality improvement initiative for a
large Southern California health
plan. “Our primary impetus for developing the beta-blocker program was
the need to reinforce existing guidelines for beta-blocker use in post-MI
patients,” says Alex Gilderman,
PharmD, director of clinical pharmacy services of Prescription Solutions.
Gilderman’s team believed that
beta-blockers were underused among
patients who had had an AMI, and
the team had done a recent study on
the use of beta-blockers among
patients with congestive heart failure.
The study of CHF patients revealed
that beta-blocker utilization was low
that listed patients identified as not
currently being prescribed a betablocker. Finally, the PBM listed recommended treatments and formulary
alternatives.
While literature that Prescription
Solutions sent was comprehensive and
“The program is very effective, and I think
that most physicians appreciate this state-ofthe-art information because their practices
are so demanding.”
—Brian K. Solow, MD, Bristol Park Medical Group
in this population as well, he explains.
“We used the mechanism of mixing
our medical data and our pharmacy
data to generate an intervention at
the provider level because we needed
to educate providers on the value of
using beta-blockers in their post-MI
patients,” Gilderman explains.
As a first step, the company studied
claims data to identify members who
had been diagnosed with an AMI,
members with contraindications to
beta-blockers, and members without
a history of beta-blocker drug therapy.
Provider-specific reports were generated to identify which post-MI members were not currently being prescribed a beta-blocker.
After studying the data, the PBM
sent letters to medical directors, primary care physicians, and directors of
independent practice associations.
The letters explained that the Drug
Regimen Review Program was
designed to monitor prescription utilization and the clinical relevance of
prescribing beta-blockers to post-MI
patients. The letter also explained the
prescribing guidelines for patients
who had experienced an AMI, and
included a “Prescribing Focus” data
sheet describing beta-blockers and a
prescribing algorithm for post-AMI.
The letter also included a physicianspecific pharmacy utilization report
4 The Quality Indicator, Pharmacy Resource/November 2001
up to date, the key to the success of the
program is that the PBM has been
adept at making physicians want to
read all of the materials, including a list
of their patients who have had an
AMI, Solow explains.
The physician then reviews patient
charts to ensure that beta-blocker
therapy has indeed been prescribed
for the patient if the patient is an
appropriate candidate. “Prescription
Solutions receives this feedback from
physicians, and we log that information,” says Glenda S. Owens, RPh,
manager of public affairs at
Prescription Solutions. “So at any
time, we can pool the data and notify
a particular medical group of its compliance with post-MI patients and
beta-blocker usage.”
Using HEDIS Data
The beta-blocker program at
Prescription Solutions focuses on the
requirements of the Health Plan
Employer Data and Information Set.
HEDIS is a data collection tool developed by employers, HMOs, and the
National Committee for Quality
Assurance, in Washington, D.C.
HEDIS is designed to help employers
to quantify and evaluate the results
and value of their health plans.
Prescription Solutions executives
believe the Drug Regimen Review
Program has been successful, and they
are considering offering it to other
clients, including commercial,
Medicare, and government health
plans, employers, and union trusts.
Overcoming Obstacles
The first phase of the beta-blocker
program, initiated in June 1998, targeted more than 660 physicians in
Southern California. After a second
campaign was launched early last
year, 640 more physicians were contacted. Since the implementation of
Phase I, the program has reached
about 1,300 physicians and more
than 4,000 patients, Owens says.
Moreover, the PBM estimates that
the program has saved an estimated
10 lives based on predicted mortalities for the population during the
study period. In addition, PacifiCare
saved over $400,000 in reduced
health care costs associated with cardiac readmissions over one year.
To provide verifiable measurement
of the postinitiative outcomes,
Prescription Solutions collaborated
with PacifiCare’s Health Improvement and Quality Measurement and
Research Department to extract and
standardize the pertinent data on
medical and pharmacy utilization
data taken from claims.
Physician reaction has been positive, Berenbeim says. “Physicians
today are exceptionally busy,” he
explains. “When they can receive
unbiased, clinically based information
of the value of a certain type of therapy, they not only appreciate it, they
use it,” he says. Doctors recognize the
clinical validity of the information
provided and the value that the
approach could have on their
patients, especially since they ultimately want what is best for their
patients, he adds.
While gathering the necessary data
and implementing the program,
Prescription Solutions experienced
the typical problems a managed care
organization would encounter when
introducing a new initiative,
Gilderman says. “We initially had
some difficulty identifying the appropriate ICD-9 codes and setting up our
computer database to examine medical claims and pharmacy claims,” he
says. By working closely with the
company’s clients, the PBM was able
to solve the problems.
Prescription Solutions also had to
get approval from PacifiCare’s medical director for the beta-blocker
guidelines and the educational materials that were disseminated. One of
the advantages of the program is that
the PBM executives developing the
program worked closely with their
newly formed health outcomes unit,
which was developed around the time
of the post-MI beta-blocker program.
“One reason we needed the expertise
of this unit was because we were getting involved with more quality ini-
merge pharmacy and medical claims.
This activity helps health outcomes
researchers to review utilization patterns from a pharmacy perspective
and shows the effect that utilization
patterns have on health outcomes
and total cost of care. “We think it’s
important to look at the total picture
of outcomes, not just the pharmacy
side,” Gilderman explains.
“All too often, we are concerned
about increasing pharmacy spending,
but we think there is another story on
the medical side,” Gilderman adds.
“We have documented some areas
where increasing pharmacy spending
might reduce medical spending, and
the beta-blocker program solidified
this concept in our minds.”
“The program is very effective, and
I think that most physicians appreciate this state-of-the-art information
because their practices are so
demanding,” Solow adds.
Despite the success of the betablocker program, experts say initia-
“Our primary impetus for developing the betablocker program was the need to reinforce
existing guidelines for beta-blocker use in
post-MI patients.”
—Alex Gilderman, PharmD, Prescription Solutions
tiatives, and we felt that it was important to have the unit’s input when
designing and measuring these interventions,” Gilderman says.
The health outcomes team has
more than 10 members. One is a
pharmacist with a PhD, and three
others are Master’s-level pharmacists
who have extensive backgrounds in
health outcomes. “We also have several statisticians who help us conduct
retrospective claims analysis by looking at pharmacy claims and medical
data,” Gilderman says.
Prescription Solutions has a data
warehouse that helps the company to
tives that address many different conditions are needed to improve quality.
“More initiatives are necessary if we
are going to improve overall quality
in both pharmacy and medical
realms,” says Nichol. “Although the
beta-blocker program provided evidence of positive impact, it is clear
that new interventions need to be
developed that can also improve
treatment outcomes for other diseases
as well.”
—Reported and written by Bethanne Black,
in Atlanta. More information on pharmacy
strategies is available on our Web site (at
www.qualityindicator.com).
The Quality Indicator, Pharmacy Resource/November 2001 5
LONG-TERM CARE
Guidelines Stress Importance
of Early Alzheimer’s Diagnosis
E
arly diagnosis and therapy are important for people with Alzheimer’s disease, according to
guidelines recently published by the American Academy of Neurology in St. Paul, Minn.
The AAN guidelines state that Alzheimer’s disease can be reliably diagnosed using a variety of tests. Early diagnosis is important because research shows current medication and care
options are most effective in treating those with mild-to-moderate Alzheimer’s disease.
“These guidelines, which represent
a review of virtually all research on
Alzheimer’s, state categorically that
an early diagnosis is possible and that
Alzheimer’s is treatable,” says Danny
Chun, spokesman for the Alzheimer’s
Association, an advocacy organization in Chicago. The guidelines,
which were published in the May 8
issue of Neurology, can help to make
physicians, pharmacists, and those
working in long-term care more
aware of treatment possibilities.
The Pharmacists’ Role
Pharmacists can play a significant role
in educating patients and caregivers
about Alzheimer’s, experts say. They
can provide information about local
and national agencies that offer support and educate patients and caregivers, says Kathleen Cameron, executive director of the American
Society of Consultant Pharmacists
Research and Education Foundation
in Alexandria, Va.
Pharmacists provide education
about medications, including adverse
drug interactions, and expected therapeutic outcomes. They monitor medication compliance, recommend
adjustments to therapy, and play a role
in educating other health care professionals about the disease through seminars and training sessions.
The pharmacological therapy of
Alzheimer’s is divided into treatment
of the cognitive symptoms of the dis-
ease (such as memory impairment,
attention deficits, and language difficulties), and behavioral symptoms
(such as depression, anxiety, agitation, aggression, psychoses, and sleep
and appetite disturbances).
Although there is no cure for
Alzheimer’s, medication can improve
quality of life and cognitive functions
among those who are mildly to moderately affected, the guidelines say.
Medications called cholinesterase
inhibitors work most effectively for
those patients and can help to alleviate certain symptoms.
the disease. The guidelines also say
that selegiline, an MAO-B inhibitor,
also may help with some symptoms.
The guidelines also call for the
implementation of regular routines
and activities, which can help with
behavioral symptoms. Physicians may
suggest strategies to assist in daily
care-giving tasks, including walking
or other light exercise that helps
reduce problem behaviors; playing
music, particularly during meals and
bathing; providing a routine for daily
activities; practicing skills and giving
positive reinforcement to increase
Pharmacists can provide information about
local and national agencies that both offer
support and educate patients and caregivers,
experts say.
Patients who receive an early diagnosis of Alzheimer’s disease can be
treated with medications determined
to be most effective in the early stages
of dementia, says neurologist Steven
DeKosky, MD, co-author of the
guidelines. However, those medications do not reverse or change the
progression of the disease, he says.
According to the guidelines,
research shows that treatment with
Vitamin E also helps to alleviate some
symptoms of Alzheimer’s disease. An
antioxidant, Vitamin E may aid in the
breakdown of free radicals that could
damage brain cells in individuals with
6 The Quality Indicator, Pharmacy Resource/November 2001
independence; and considering medications to help alleviate depression,
agitation, and psychosis.
Improving Quality of Life
To develop the guidelines, experts
reviewed more than 1,000 studies on
the disease. The AAN recommendations include how to recognize early
signs of Alzheimer’s, how to diagnose
the disease, when medication is most
effective, and what types of support
can improve quality of life for patients
and caregivers. The multidisciplinary
panel of experts that developed the
guidelines included neurologists, a
Today, more than two million Americans have Alzheimer’s, and that
number is projected to be as high as 14 million within 50 years.
primary care physician, psychiatrists,
a geriatrician, a psychologist, a nurse,
a social worker, family members caring for dementia patients, and representatives from the Alzheimer’s Association. The American Association
of Neuroscience Nurses in Glenview,
Ill., and the American Geriatrics
Society in New York have endorsed
the guidelines.
The guidelines stress that Alzheimer’s disease is recognizable, and
can be differentiated from normal
aging. It can be reliably diagnosed
through an examination that includes
complete medical and psychiatric histories; a neurological exam; lab tests to
rule out anemia, vitamin deficiencies,
and other conditions; and a mental
status exam to evaluate the patient’s
thinking and memory. Talking with
family members or caregivers should
also be part of the assessment. The
AAN guidelines call for early use of
specific criteria for the clinical diagnosis of probable Alzheimer’s that
have been established by various
agencies, including criteria from the
Diagnostic Statistical Manual-IV
(published by American Psychiatric
Publishing Inc., Washington, D.C.),
and diagnostic guidelines from the
National Institute of Neurological
and Communicative Disorders and
Stroke in Bethesda, Md.; and the Alzheimer’s Association.
The Role of Education
Knowledge about treatment choices
enhances opportunities for both early
diagnosis and treatment attempts to
retard the development of the disease.
“Research shows that learning about
Alzheimer’s disease is one of the best
ways to help patients and their families,” says Bill Thies, vice president of
scientific and medical affairs at the
Alzheimer’s Association.
The biggest risk factor for Alzheimer’s disease is growing old. Alzheimer’s
is an ultimately fatal disorder that
begins to assault the brain years
before problems with memory or
learning make the disease’s presence
apparent, says Trey Sunderland, MD,
chief of geriatric psychiatry at the
National Institute of Mental Health
in Bethesda, Md.
Disease Stages
The disorder is rare in people younger
than age 60, but its frequency doubles
every five years after age 65.
According to the Alzheimer’s
Association, it affects one in 10 people over age 65 and nearly half of
those over age 85. In the next halfcentury, as the population ages, the
number of Americans with Alzheimer’s disease will quadruple. The
current total is estimated at between
two million and four million and is
projected to be as high as 14 million
by 2050. More than 19 million
Americans say they have a family
member with the disease. The average
lifetime cost per Alzheimer patient is
$174,000 according to the Alzheimer’s Association.
The AAN guidelines incorporate
warning signs of common symptoms
for the disease that were developed
by the Alzheimer’s Association.
Individuals who exhibit several of
these symptoms should see a physician for a complete examination.
The symptoms include memory loss
that affects job performance skills;
difficulty performing familiar tasks;
problems with language; disorientation to time and place; poor or
decreased judgment; problems with
abstract thinking; misplacing objects;
changes in mood, behavior, or personality; and loss of initiative.
Alzheimer’s is a particularly insidi-
ous disease because of the slow progression of symptoms. In fact, many
years may pass before the patient presents for evaluation, experts say. The
average clinical course of the disease
from diagnosis to death is typically
five to nine years, although this time
may vary, according to research by
Marshall Folstein, MD, chairman of
the Department of Psychiatry at Tufts
University School of Medicine, a
division of the New England Medical
Center in Boston. The three stages of
Alzheimer’s disease—early, middle,
and late—correspond to the severity
of symptoms.
Clinical Issues
As the disease progresses to the late
stage, the patient’s ability to communicate and function independently
deteriorates further, says Folstein.
Short- and long-term memory and
language skills deteriorate dramatically, and patients may be unable to initiate speech or may become mute,
experts say. Cells in the motor cortex
of the brain are affected, and patients
may be unable to walk unassisted and
may become bedridden and dependent on caregivers. Death of the
Alzheimer’s disease patient is usually
due to infection, aspiration, embolus,
or malnutrition.
Because a definitive diagnosis of
Alzheimer’s disease can be made only
through an autopsy, a clinical diagnosis of probable Alzheimer’s relies on
clinical criteria and the exclusion of
reversible causes of dementia, say
experts. Using the available criteria,
Alzheimer’s disease can be accurately
diagnosed in 86% to 92% of cases,
according to researchers.
—Reported and written by Martin Sipkoff, in
Gettysburg, Pa. More information on pharmacy strategies is available on our Web site (at
www.qualityindicator.com).
The Quality Indicator, Pharmacy Resource/November 2001 7
DISEASE MANAGEMENT
Studies Raise Concern About
Weight, Antipsychotic Medication
R
ecent studies show a significant relationship between weight gain and the use of atypical
antipsychotic medications among patients being treated for schizophrenia. The relationship is of sufficient concern to researchers to warrant considering weight gain as a modifiable health risk in the choice of atypical antipsychotics, experts say. This relationship is particularly worrisome because weight gain can lead to diabetes and heart disease, researchers say.
Although a causal relationship
between the use of atypical antipsychotics and diabetes “has not been
definitively proven, the number of
cases reported in the literature suggests
there might be an association between
atypical antipsychotic medications
and diabetes mellitus,” says John
Muench, MD, who has studied the
issue. “Physicians who care for patients
with schizophrenia should be aware of
this possible association.” Muench is a
physician with the Department of
Family Medicine at Oregon Health
Science University in Portland.
Unintended Consequences
A casual relationship between
antipsychotic medications and
weight gain has been established, say
experts. Weight gain associated with
antipsychotic medication use has
been a concern to physicians and
pharmacists since conventional
antipsychotic drugs, such as chlorpromazine, were introduced in the late
1950s, says Herbert Meltzer, MD, a
psychiatrist and professor in the
Department of Psychiatry at Vanderbilt University School of Medicine in
Nashville. That concern has been
growing in recent years, he says,
because the medical community has
observed an increased risk of weight
gain as a result of the use by patients
of the atypical antipsychotic drugs
introduced in the 1990s.
The atypical antipsychotic drugs
appear to result in a significantly
greater increase in weight than the
older drugs do, researchers say. “It is
troubling that some atypical antipsychotic drugs appear to have a greater
weight gain liability than the conventional antipsychotic drugs. In addition,
some atypical antipsychotic drugs have
adverse effects on blood levels of lipids
and glucose,” Meltzer says.
Because the relationship between
weight gain and diabetes is well
known, “potential weight gain
through the choice of antipsychotic
medications should be of concern in
treating patients with schizophrenia,
particularly those whose family history implies a propensity toward diabetes,” says John Newcomer, MD, an
associate professor of psychiatry at the
Washington University School of
Medicine in St. Louis. “With regard
to weight gain, the choice of a particular antipsychotic drug should defi-
nitely be considered a modifiable
health risk.” Newcomer is a leading
researcher in the metabolic side
effects of atypical antipsychotic drugs.
Reports by Meltzer and other
researchers who examined the relationship between atypical antipsychotic drugs and weight gain were published this year in a special supplement
of the Journal of Clinical Psychiatry
(issue 62, supplement 7), by Physicians
Postgraduate Press Inc., in Memphis,
Tenn. In the supplement, researchers
reported on a review of the evidence of
weight gain among patients with schizophrenia who were treated with atypical antipsychotic drugs. “The results
clearly demonstrate that this problem
should be of concern to every clinician,” Meltzer writes in his introduction to the supplement titled, “Weight
Gain: A Growing Problem in
Schizophrenia Management.”
The Pharmacists’ Role
As part of the medical community,
pharmacists should be aware of the
data being gathered by studies on
atypical antipsychotic drugs because
pharmacists are in a position to advise
patients and physicians on possible
(Continued on page 9)
“Potential weight gain through the choice of antipsychotic medications
should be of concern when treating patients with schizophrenia, particularly those whose family history implies a propensity toward diabetes.”
—John Newcomer, MD, Washington University School of Medicine
8 The Quality Indicator, Pharmacy Resource/November 2001
DISEASE MANAGEMENT
(Continued from page 8)
side effects of prescribed medications,
says Tricia Cash, PharmD, owner of
Talbert Consulting in Stanley, N.C.
“Pharmacists play a vital role in
recommending approaches to maximize efficacy, ameliorate adverse
effects, and identify reasons for the
patient noncompliance encountered
with antipsychotic medications,”
Cash says. “Many clinicians are turning to atypical antipsychotic drugs for
improved efficacy and reduced
adverse effects. Because of their better
side-effect profile, better compliance,
and greater efficacy, the new antipsychotic medicines are now considered
first-line medications in the treatment of schizophrenia and related illnesses. Pharmacists and other clinicians should become familiar with
this new class of medications.”
Safety is a key issue when evaluating antipsychotic therapies, experts
say. Older agents were marked by
extrapyramidal side effects (EPS) and
tardive dyskinesia (TD). EPS can
include grogginess or lack of focus.
TD is involuntary jerky movements
associated with long-term use of
antipsychotics. Minimal or no EPS is
the most salient defining clinical feature of the newer atypical antipsychotic medications, contributing to
their widespread adoption. However,
other safety concerns, such as weight
gain, have resulted in renewed attention for these drugs.
The evidence of a relationship
between weight gain and antipsychotics is very strong, say the studies
published in the Journal of Clinical
Psychiatry supplement. “Data strongly
suggest that many antipsychotic
drugs, especially the so-called new or
atypical drugs, are associated with
weight gain,” says Daniel E. Casey,
MD, professor of psychiatry at the
Oregon Health and Science
University in Portland, and director
of psychiatry and psychopharmacolo-
gy research at the Veterans Administration Medical Center, also in
Portland. Casey was co-author of a
study in the supplement titled, “The
Pharmacology of Weight Gain With
Antipsychotics.” Casey’s study and
others conclude that weight gain
should be a consideration when
physicians prescribe or pharmacists
dispense antipsychotic medications.
Researchers agree that safety issues,
especially those related to the comor-
treatments for certain patients,
including the number and types of
EPS. More conclusive research on
whether atypical antipsychotic drugs
contribute directly to an increased
rate of diabetes mellitus or contribute
indirectly, through weight gain, is
ongoing. Therefore, Newcomer and
other researchers say physicians and
pharmacists should be aware of existing research and data when making
decisions about which drugs to use.
Researchers agree that safety issues, especially those related to the comorbid symptoms
of weight gain associated with diabetes, are a
major concern when patients are being treated
with atypical antipsychotic drugs.
bid symptoms of weight gain associated with diabetes, are a major concern
when patients are being treated with
atypical antipsychotic drugs.
“These drugs are of enormous therapeutic benefit to many patients,”
Casey says. “Although they generally
have a lower burden of side effects
than older agents, many promote substantial weight gain, a concern to the
patients within the schizophrenia
population, which is already prone to
an increased mortality rate from cardiovascular disease, epilepsy, accidents, lung cancer, substance abuse,
and treatment refusal. Evidence
shows that increased weight gain contributes significantly to impaired glucose tolerance (which can result in
diabetes) and hypertension (which
can result in cardiovascular disease).”
More Research Needed
The degree of weight gain associated
with specific antipsychotic drugs will
vary depending on many factors,
including a hereditary disposition
toward obesity and preexisting
weight. Variations also are found in
the overall effectiveness of specific
“I am not prepared at this point to
recommend one drug over another
for all patients,” Newcomer says. “But
weight gain is such a significant issue
that it must be considered.”
The effect of atypical antipsychotic
drugs on brain chemistry apparently is
a causal factor in weight gain among
patients, Casey says. But the precise
nature of that effect—in other words,
which chemical interactions caused by
specific drugs result in weight gain—
has not yet been established. Given
that atypical antipsychotic medications have broad pharmacologic profiles, it is likely that multiple neurotransmitter systems and receptors are
affected by antipsychotics moderate
weight gain, including the systems that
govern appetite, he explains.
Many patients with schizophrenia
who are being treated with atypical
antipsychotic drugs report a greatly
increased appetite, particularly cravings for carbohydrates, says Lorraine
Willows, a clinical dietitian at
Kingston Psychiatric Hospital in
Kingston, Ontario. “I have seen other
patients with schizophrenia, however,
who have gained significant weight
(Continued on page 10)
The Quality Indicator, Pharmacy Resource/November 2001 9
DISEASE MANAGEMENT
(Continued from page 9)
with little or no increase in appetite,”
she says. “Weight gain tends to begin
quickly and continue for an extended
period, up to and beyond one year.”
The issue of weight gain is particularly troubling as it concerns patients
with schizophrenia. Several studies
conducted over the last several years
indicate that between 30% and 60%
of such patients are obese when they
begin treatment, possibly the result of
unhealthy eating habits and lack of
exercise, says David Allison, PhD.
Allison is a professor and researcher
at the Department of Biostatistics at
the University of Alabama in Birmingham. He was co-author, with
Casey, of a study titled, “Antipsychotic-Induced Weight Gain: A Review
of the Literature,” in the journal supplement.
Another important factor for physicians to consider when prescribing
antipsychotic medications is that as a
result of their erratic behavior,
patients with schizophrenia tend to
receive sporadic and often inferior
medical care. “The information we
have on obesity among patients with
schizophrenia suggests that weight is a
substantial problem that is likely to be
impairing the health of those individuals, especially because many of the
adverse effects of obesity are conditions for which schizophrenic
patients tend to be underdiagnosed
and undertreated,” Allison explains.
Enhanced Efficacy
Since they were introduced in the
1950s, the conventional antipsychotic agents have effectively controlled
the symptoms of schizophrenia.
Weight gain was observed with the
use of the conventional antipsychotics, but that side effect was “overshadowed by the other substantial
side effects of the older generation of
neuroleptic agents,” Meltzer says.
Physicians and pharmacists focused
on the prevalence of EPS, for example, and little research was conducted
on associated weight gain.
The older drugs frequently produce
TD, says Michael J. Burns, MD, a
medical toxicologist with the Division
of Toxicology in the Department of
Emergency Medicine at Beth Israel
Deaconess Medical Center in Boston.
“The high incidence of EPS and TD
often leads to patient noncompliance
and a high incidence of treatment failure and disease relapse,” he says. Burns
has written about atypical antipsychotic drugs and EPS, including an
article, “The Pharmacology and
Toxicology of Atypical Antipsychotic
in February 2001). “Clinically, atypical agents achieve an enhanced efficacy for the full spectrum of schizophrenic symptoms, have a superior
side-effect profile, and demonstrate
improved patient compliance,” Burns
says. “Because of their superior profiles, the atypicals are rapidly replacing conventional agents for nearly all
schizophrenia subgroups, including
first-episode, treatment-resistant, partially responding, relapsing, and stable-but-chronic patients.”
“The clear beneficiaries of this new
pharmacotherapy of schizophrenia
are the millions of patients afflicted
with this disease,” Burns continues.
“Because of their better side-effect profile,
better compliance, and greater efficacy, the
new antipsychotic medicines are now considered first-line medications in the treatment of
schizophrenia and related illnesses.”
—Tricia Cash, PharmD, Talbert Consulting
Agents,” in the January issue of the
Journal of Toxicology: Clinical Toxicology, published by Marcel Dekker Inc.
in New York City.
“The need for antipsychotic agents
with improved efficacy and side-effect
profiles led to the development of
atypical antipsychotic agents,” Burns
explains. The atypical antipsychotics
introduced in the 1990s represent “a
new era in the pharmacotherapy of
psychotic disorders,” he adds.
Antipsychotic agents are considered
atypical if they produce minimal EPS
at clinically effective antipsychotic
doses, have a low propensity to cause
TD, and treat the symptoms of schizophrenia effectively.
Since 1990, the Food and Drug
Administration has approved five
atypical antipsychotics: clozapine,
risperidone, olanzapine, quetiapine,
and ziprasidone (which was approved
10 The Quality Indicator, Pharmacy Resource/November 2001
“Since their introduction to the U.S.
market, the atypical agents have
largely displaced traditional agents as
first-line drugs for the treatment of
schizophrenia. Although the costs for
atypical agents are much higher,
pharmacoeconomic studies have suggested that these costs are offset by
improved patient outcomes and
reduced rates of hospitalization.”
The key issue today, says Newcomer,
is for clinicians to understand and
appreciate the implications of potential adverse events, such as weight
gain, in treatment decisions. “We are
reaching a stage where we are becoming able to make more informed treatment decisions for patients with schizophrenia,” he says.
—Reported and written by Martin Sipkoff, in
Gettysburg, Pa. More information on pharmacy strategies is available on our Web site
(at www.qualityindicator.com).
COVER STORY
(Continued from page 1)
encompassed the steps involved in
baseline screening for potential medication errors and data collection.”
Specifically, the pharmacy technicians responsibilities include:
• Interviewing patients on admission
to verify allergies, medication use,
and compliance
• Screening laboratory and microbiology reports for predefined outlying values
• Coordinating the pharmacists’
continuity-of-care forms, including
prescriptions the patient has
received both in and out of the
hospital
• Calculating creatinine clearances
when indicated by lab results
showing elevated levels
• Screening for and monitoring of
deep vein thrombosis prophylaxis;
stress ulcer prophylaxis; blood
sugar and vital signs; and total parenteral nutrition orders and lab
work.
With the technicians added to the
department, the pharmacists are
freed up to accompany physicians on
their rounds as part of various medical, surgical, and critical care teams.
The department has also seen a number of significant improvements. For
example, lab data and medication
profiles are screened more consistently for potential errors; allergy and
medication use is verified more consistently; and coordination of patient
information has improved.
An Academic Medical Center
In a program similar to that of the
Phoenix VA hospital’s inpatient
pharmacy program, the Duke
University Medical Center re-engineered operations in its pharmacy
department. The result was that pharmacy technicians had more time to
devote to clinical activities—something they had expressed great interest in before the re-engineering.
Unlike the technicians in the VA’s
program, however, pharmacy technicians at the medical center had been
working within the pharmacy department for several years, explains
Michelle Giesler, PharmD, a clinical
pharmacist in the Division of Surgery.
The Division of Surgery currently has
236 beds in nine units.
Before the restructuring, pharmacists and technicians worked entirely
out of pharmacy satellites, meaning
that their location was set apart from
the central pharmacy in the hospital.
ity and communication capabilities of
pharmacists and technicians. The
pharmacists were given laptop computers, and technicians were given
access to mainframe order-entry computers that could facilitate their ability to do their jobs in the “hub” of
patient care activity—on the patient
care floors—versus from a distance,
such as their former locations at the
satellites. Technicians also were given
pagers so that the pharmacists and
health care providers in patient care
units could reach them quickly.
When a medical center added technicians to
its pharmacy department, the pharmacists
were freed up to accompany physicians on
their rounds as part of various medical, surgical, and critical care teams.
All communication between physicians and other providers in patient
care units and pharmacy staff in the
satellites occurred by telephone or
through nursing personnel visits.
Under this arrangement, technicians’
responsibilities included making
hourly trips from the pharmacy to
each patient care area to collect
orders and deliver medications, entering physician orders into the pharmacy computer system, preparing medication orders for delivery, preparing
reports for the pharmacists, and collecting quality improvement data.
The restructuring of the department resulted in several changes that
promoted a patient-focused interdisciplinary partnership that included
technicians as key members of the
team of health care providers. Now,
pharmacists and technicians work
closely and are assigned to specific
patient care units.
Under the current arrangement,
two technological changes were
introduced that facilitated the mobil-
The tasks considered for reassignment to technicians were evaluated
based on the needs of the pharmacy
and were ranked in terms of value to
the pharmacists. Pharmacists and
technicians selected the tasks to
implement, and then the technicians
were trained in completing them.
Clinical Assignments
One of the new clinical tasks that the
technicians assumed involved collecting data for pharmacokinetic
monitoring. Technicians were asked
to collect routine daily lab values for
patients with current running orders
for aminoglycosides and vancomycin
and for starting a new pharmacokinetic sheet on receipt of a new order.
Another clinical task involved collecting allergy data. Technicians were
asked to collect data on patients’
allergies and to clarify reactions to
allergies listed in the medical chart, as
necessary, thereby freeing up pharmacists from that responsibility.
One result of having the techni(Continued on page 12)
The Quality Indicator, Pharmacy Resource/November 2001 11
COVER STORY
(Continued from page 11)
cians assume these new clinical roles
is that pharmacists have more time to
participate on rounds with physicians
and can be more involved in drug
therapy decisionmaking, including
advising physicians on appropriate
drug use, advising nurses on proper
medication administration, and
counseling patients on drug therapy.
What’s more, technicians have
expressed improved job satisfaction in
their new roles and the teamwork
approach has helped to reduce costs
and improve efficiencies in patient
care, Giesler says.
A Community Pharmacy
Zive Pharmacy & Surgical Inc. has
served the Bronx, N.Y., for more than
30 years. Recently it formalized its
disease state management efforts into
Zive Disease State Management Co.
A family-owned pharmacy that specializes in treating patients with
numerous diseases, including asthma,
diabetes, and hypertension, Zive
Pharmacy has developed an educational program for persons with HIV
that has resulted in improved medication adherence and improved patient
satisfaction. Central to the program is
a pharmacy technician who is a
patient services manager. The pharmacy employs three pharmacists,
including Joel Zive, RPh, the son of
the company’s founder.
Since 1993, when the pharmacy
began seeing people needing HIV
medications, Zive had noticed that the
rate of medication compliance among
this population could be improved.
“Typically, people with HIV must take
a multitude of retroviral medications,
which can exceed 20 pills a day,” Zive
says. “The side effects can be debilitating, and patients can get discouraged.”
Poor medication adherence reduces
treatment options, quality of life, and
survival time, he says.
Aware of how techs can improve a
practice, Zive hired a certified pharmacy technician in 1999 to help
improve adherence. The technician,
Jay Hager, CPhT, established a position of HIV patient service manager
for the practice, Zive says. Hager has
over 25 years in pharmacy practice
and a degree in community health
education.
“We knew we had to do more than
call people on the phone to remind
them to refill their prescriptions,”
Zive says.
Zive, Hager, and the other two
pharmacists integrated the dispensing
function of the pharmacy with intensive patient medication education
and counseling. As a first step, the
pharmacy team began tracking
lems that may require intervention by
a pharmacist or a physician.
In addition, Zive also conducts regular HIV/AIDS educational meetings
in the community. For the last six
years, for example, the pharmacy has
conducted community awareness
days on asthma, diabetes, and hypertension. It also conducts hypertension
screenings.
The Technicians’ Role
In tracking patient adherence rates
for 12 months last year among the
patients with HIV, adherence rates
ranged from 85% to 94%, Zive says.
Though no baseline adherence rates
were calculated, the national average
for antiretroviral adherence is approx-
The pharmacy technicians have more job satisfaction in their new roles, and the teamwork
approach has helped to reduce costs and
improve efficiencies in patient care.
patients’ medication refill rates,
which were collected in a computer
database that was separate from the
prescription records. Armed with this
information, the team could see the
population’s compliance patterns and
develop improvement strategies.
In addition to refill rates, Zive says
that other lab data, such as CD4 viral
load (which shows the degree that the
HIV has progressed), help to form a
picture of each patient’s overall health
status. A file is developed for each
new patient, and a member of Zive’s
team schedules a time to meet with
each patient. At this 20-minute meeting, the team member asks a series of
questions related to the person’s
health and quality of life. Hager and
Zive review the information gathered
and develop a written treatment plan.
The sheet is printed for the patient
and reviewed by the one of the pharmacists, who can identify any prob-
12 The Quality Indicator, Pharmacy Resource/November 2001
imately 30%, he adds.
“In summarizing the achievements
of the Innovations Award winners,
each had a belief that processes could
be improved and that techs had a crucial role to play in making this happen,” says Bruce Wearda, RPh, pharmacy manager for Long’s Pharmacy in
Bakersfield, Calif., and one of the
award judges. “We also need to recognize that they responded voluntarily,
under no obligation other than what
their vision dictated.”
Murer agrees, saying, “We take
great pride in the innovations award
program. Efforts to enhance patient
care, reduce medication errors, and
manage patients’ chronic diseases
serve as best practices for the over
86,000 CPhTs nationwide.”
—Reported and written by Susan Howell, in
Fairport, N.Y. More information on pharmacy strategies is available on our Web site
(at www.qualityindicator.com).
INTERVIEW
Pharmacists Seek to Address
Work Force Issues in Connecticut
Margherita Giuliano,
RPh, has been executive vice president of the
Connecticut Pharmacists Association in
Rocky Hill for the past
two years and has been a practicing pharmacist for 20 years. Giuliano is a member of the Connecticut Pharmacy
Coalition for Patient Care, a group of
pharmacists, regulators, and educators
that seeks to foster changes in how pharmacies operate. In this interview, she discusses the goals of the coalition and issues
the pharmacy profession faces with contributing editor Richard L. Reece, MD.
Q:
A:
What is the mission of
Connecticut Pharmacy Coalition
for Patient Care?
The coalition was formed in
May 2000 to address the challenges facing our profession. It is composed of hospital, long-term care,
independent, and chain pharmacists,
as well as state regulators and representatives from the state pharmacy
commission and the University of
Connecticut School of Pharmacy.
What are some of these challenges pharmacists face?
The first challenge is to
address the shortage of pharmacists. In 1999, a study of the pharmacy work force by the federal
Health Resources and Services
Administration (HRSA) clearly indicated evidence of a critical pharmacist shortage. One factor contributing
Q:
A:
to the shortage is that retail pharmacy, or community pharmacy, is no
longer very appealing to pharmacists
and other professionals in the field.
Also, more women have entered the
profession, and women are more likely to seek part-time hours. Finally,
other career opportunities, such as
working for pharmaceutical manufacturers or educational institutions,
have drawn pharmacists out of traditional jobs.
The work force shortage is exacerbated by the concurrent growth in
the number of prescription medications available to the public.
Prescription volume is estimated to
double within the next four years, and
will increase even more quickly if
Medicare pharmacy benefits are
expanded. At the same time, the
pharmacy work force is expected to
increase by only about 6%. Therefore,
a real crisis is developing.
Third-party payers represent another challenge. Those in the pharmacy
profession have faced years of difficulties in dealing with these payers,
which have an excessive role in making medical judgments that affect the
delivery of health care in the practice
of pharmacy.
Another problem with payers is
inadequate reimbursement. Pharmacists are simply not being reimbursed
for cognitive services that they offer
to patients. Reimbursement is based
solely on product, with no consideration of the daily professional services
pharmacists provide to patients. As a
result, reimbursements are insufficient to sustain the profession.
Pharmacy is a health profession in a
retail business.
Finally, pharmacists are experiencing tremendous burnout and frustration because they are spending a significant amount of time resolving
insurance issues. Pharmacists are educated to help patients manage drug
therapy; instead, they spend 20% or
more of their time dealing with insurance issues, rather than taking care of
patients.
Given that pharmacists work in a
fragmented industry, how do they
achieve any collective bargaining leverage
with regard to managed care plans?
Pharmacists have no leverage,
which has always been an
important issue for us. Managed care
companies argue that we have negotiating leverage because we do not
have to accept the contract being
offered. Realistically, if a pharmacy is
in an area where 20% of its patient
base is covered by a particular insurance plan, the pharmacy has to
accept that contract. The options for
pharmacists, therefore, are dying
quickly without the contract or dying
slowly after signing it.
Is your plight similar to that of
physicians, who are between
managed care companies and patients?
Yes. Like physicians, our profits are being squeezed.
Reimbursements are so low that our
profit is based on prescription volume. Pharmacy has always been a
Q:
A:
Q:
A:
(Continued on page 14)
“Reimbursement is based solely on product, with no consideration of
the daily professional services pharmacists provide to patients. As a
result, reimbursements are insufficient to sustain the profession.”
The Quality Indicator, Pharmacy Resource/November 2001 13
INTERVIEW
(Continued from page 13)
product-based service, and so pharmacy profits are caught between drug
costs and decreasing drug reimbursements. As a result, pharmacies’ net
profits have steadily been decreasing.
Pharmacies are currently working on
a net profit of around 2%, and despite
efficiency improvements, pharmacists
are struggling to make ends meet.
What’s more, patient safety is affected. Pharmacists want to fill prescriptions correctly and safely because they
have their patients’ best interests at
heart, but pharmacists who are under
pressure could possibly make errors.
How does the coalition propose to
address these issues?
In July, we approved a position
paper that suggests changes in
third-party reimbursement formulas
and state laws and regulations. In
general, we want to guarantee sufficient manpower in the profession to
meet the escalating demand for pharmacy services, ensure proper support
in meeting this demand, and allow
pharmacists to become more
involved with the patients they serve.
What are the changes in reimbursement you suggest?
The coalition believes that
pharmacists need to transition
from a product-based system to a
patient-based system of reimbursement. We want pharmacists to be
paid for the services they deliver, not
just the number of prescriptions they
dispense. The plan outlines such a
change in third-party reimbursement
formulas. Reimbursement should
include a fair price for the product, a
reasonable fee for dispensing that
product, and fair reimbursement for
the time the pharmacist spends on
utilization review and patient counseling. The plan also calls for reducing
the pharmacist’s role in haggling with
insurers over which pills they will pay
for; this chore eats up an inordinate
amount of a pharmacist’s time. The
Q:
A:
Q:
A:
pharmacist’s role in dealing with
insurers over plan issues should be
reduced and pharmacists should
spend more of their time educating
patients on the proper use of their
medications.
What changes will allow you to
focus more on patient service?
Pharmacists play an important
role in educating patients on
their medications. But pharmacists
spend more than 20% of their time
resolving third-party reimbursement
issues. Relieving these issues will free
up valuable time that could be spent
with the patient.
Furthermore, several solutions center on the use of technology, including robotic systems that can provide
Q:
A:
requirements are met, such as the
presence of advanced technology or
enhanced education for technicians.
The commission has recently appointed a task force to review technician
ratios and suggest changes for the next
legislative session.
We also promote regulatory
changes that will support pharmacists
in managing patient medication therapy. For example, approximately 30
other states allow collaborative practice between pharmacists and physicians. Connecticut law should also
allow pharmacists and doctors to
work collaboratively so that pharmacists can adjust medications that now
require physician approval. We need
to amend the statutes and regulations
“We need to amend the statutes and regulations
so that we can use our skills in the direct management of the patient’s medication therapy.”
relief from repetitive and mechanical
tasks. Using advanced technology
also can result in fewer medication
errors. So, these technologies have
the potential to enhance operational
efficiencies and improve safety.
The state Department of Consumer
Protection reviews computer systems
and some robotics to ensure compliance with state laws. We have to
amend regulations to free pharmacists
from mechanical functions that do
not require our specialized professional judgment.
In addition, a larger number of
pharmacy technicians per pharmacist
would free pharmacists to spend more
time with patients. In a community
setting, the ratio is two technicians to
one pharmacist, and these technicians
must be under the direct supervision
of the pharmacist. The Connecticut
Commission of Pharmacy has a provision that a community pharmacy can
request a three-to-one ratio if certain
14 The Quality Indicator, Pharmacy Resource/November 2001
so that we can use our skills in the
direct management of the patient’s
medication therapy.
Disease management is another
way pharmacists can focus on patient
care. Many pharmacists have continued their education to receive credentialing in certain disease states
because they know the value of
patient education regarding drug
therapy. Pharmacists can play an
active role in counseling patients suffering from chronic diseases, such as
hypertension, diabetes, hyperlipidemia, and asthma. The disease management counseling and medication
management that pharmacists provide could help avoid costly hospital
visits and ultimately save money.
Is part of your goal to ensure that
pharmacists play a role in the
clinical treatment team?
Yes. Pharmacists are important
members of the health care
team, but they need to have greater
Q:
A:
INTERVIEW
involvement. Pharmacists are accessible to patients, who probably see a
pharmacist more often than any other
health care provider. The education
that pharmacists have can be leveraged to a greater degree. After all,
pharmacists are the drug experts.
They go through six years of clinical
education, which when combined
with their access to patients, enable
them to play an important role in
patient care.
What is the current relationship
outside of institutions between
physicians and pharmacists?
Even within an institution,
where physicians and pharmacists collaborate, the pharmacists
legally cannot change medications
without approval from the physician.
When we talk about collaborative
practice, we refer to a voluntary
agreement between physicians and
pharmacists to manage a patient’s
drug therapy. Some pharmacists have
developed trust-based relationships
with certain physicians, and they
work together on many different
issues—especially when the physicians have patients with special
needs, such as diabetes or asthma, and
the pharmacists can work with them
to help manage the patient’s drug
therapy. Again, in 30 other states,
physicians and pharmacists can work
together and pharmacists are allowed
to make medication adjustments as
determined by a protocol, and then
inform the physicians of changes. We
believe that Connecticut law should
be changed to follow this policy.
Apparently, the Connecticut
Department of Consumer
Protection, the regulatory agency that
oversees pharmacies, is concerned that,
given the explosion of prescriptions and
the shortage of pharmacists, medication
error rates will escalate.
Part of the rise in the number
of medication errors is due to
Q:
A:
Q:
A:
“Pharmacists go through six years of clinical
education, which when combined with their
access to patients, enable them to play an
important role in patient care.”
the fact that pharmacists are not able
to spend the time needed with
patients. Churning out a high volume
of prescriptions can be dangerous,
especially when dispensing powerful
medications. The Institute of Medicine’s report on medical errors, To Err
Is Human, documents that pharmacist interventions reduce errors and
improve patient outcomes. Given the
prescription volumes predicted for
the near future, prescription error is a
concern.
In the past few years, questions
about which medications should
be listed on formularies and which ones
should be omitted have increased. How
do pharmacists negotiate this tension?
A significant portion of the
time pharmacists must spend
dealing with insurance issues has to
do with formulary maintenance. If a
particular plan will not pay for a particular brand name drug, the prescription has to change to either a generic
or another brand name drug. The
brand-to-generic issue is becoming
more widely accepted by the public.
Patients need to become more cognizant of what medications their plan
covers. However, the changes that
occur when a patient has been successful on one medication and has to
be switched to another because of a
change in coverage are frustrating to
the patient, the pharmacist, and the
physician.
The public is purchasing more
herbal supplements and alternative medicines. What is the role of the
pharmacists in mediating that situation?
Many pharmacists are becoming more educated on herbal
Q:
and alternative medicines and keeping up to date on interactions.
Unfortunately, we do not know all of
the pills that our patients take
because we cannot control the medications they get from other pharmacies or from mail order companies,
and we certainly cannot control the
herbals they purchase over the
counter. At a minimum, we stress
that it is best to centralize purchases
from one pharmacy so that potential
interactions can be caught. But
because there is no real regulation of
herbal products and alternative medicine, offering advice on these supplements is challenging.
What are some of the complexities pharmacists face when dealing with older patients, who often take
many different medications?
We can give seniors all of the
medications they need, but if
they do not know how to take them
safely, we will have a chaotic and dangerous situation. In the absence of
guidance and education, adverse
events will occur frequently. That is
why on a national level, pharmacy
groups are promoting a pharmacy
benefit rather than a drug benefit.
The drug benefit President Bush has
suggested simply gets patients their
drugs through a discount. But the discount will not really help seniors,
who need real coverage not discounts.
If they cannot afford a medication for
$100, chances are they will not be
able to afford one for $80 either.
A:
—Edited by Deborah J. Neveleff, in North
Potomac, Md. More information on pharmacy strategies is available on our Web site (at
www.qualityindicator.com).
Q:
A:
Q:
A:
The Quality Indicator, Pharmacy Resource/November 2001 15
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November 2001
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