Hospital Pharmacy in Canada Hey Kid … what do you do now ? Jean-François Bussières B Pharm MSc MBA FCSHP Chef, département de pharmacie et unité de recherche en pratique pharmaceutique Professeur agrégé de clinique Faculté de pharmacie, Université de Montréal Membre du comité de rédaction Rapport canadien sur la pharmacie hospitalière

Match plan Objective : provide participants with an overview of the alignment of hospital pharmacy practice (e.g. clinical pharmacy) with the evidence –What do we Know ? –What do we Ignore ? –What should we Do ?

Who are we ? Response rate = 74 % Teaching institutions = 26 % Johnson N et al. Hospital Pharmacy in Canada

Who are we ? Please consider absolute numbers … but prefer ratios when available Always understand what’s behind the numbers Johnson N et al. Hospital Pharmacy in Canada

Clinical practice models Clinical pharmacy has celebrated its 40th anniversary in 2006 There are many models and philosophy Traditional clinical services –range of services based on a medication or a particular pharmaceutical function designed to optimize a given result for the patient; for example pharmacokinetic services, total parenteral nutrition (TPN) monitoring services and so on. Pharmaceutical care –organized delivery of pharmacotherapeutic services to achieve well- defined therapeutic results. In particular, it means designing, applying and managing a therapeutic care plan of monitoring, prevention and solution of pharmacotherapeutic problems, potential or real. Interdisciplinary pharmacy practice Total pharmacy practice

Clinical practice models Traditional (89 %) and pharmaceutical care (82 %) are largely implemented Pharmacy departments use both models and an important % or beds are still non covered Johnson N et al. Hospital Pharmacy in Canada

Clinical practice models Pharmaceutical care AND absence of clinical services have progressed over the last 10 year-period

Clinical practice models The proportion of beds covered by PC has increased while the proportion of beds uncovered has decreased

Clinical practice models But we ignore … –If this distinction between models is still useful and reliable to report ? –If one model is superior to the other in all cases or some cases ? –What criteria should influence the implementation of one model or the other ? What is the best model mix ? –What will be the impact of the entry-level Pharm. D. on practice models

Clinical practice models So we have to … Ensure that each pharmacy department has a reproductible framework for clinical pharmacy services Ensure a better coherence between academia, hospital and community pharmacy practice Document and publish successful practices from role model

A new entry-level Pharm. D. Transversals Professionnalism Communication Team work and interdisciplinarity Scientifical reasoning and critical thinking Autonomy in learning Leadership Specifics Pharmaceutical care Service to the community Pharmacy management and operations

A new entry-level Pharm. D.

Module A – Drugs and the human Module B – Drugs and society Module C – Labs Module D – Integration activities Module E – practical training/internship Module F – optional courses

Staffing There are different ratios that can be used to compare pharmacy staffing to others e.g. doses dispensed/y, case-mix index-ajusted patient- days, admission, occupied beds etc. Gupta SR et coll. AJHP 2007; 64:

Staffing 15 FTE pharmacists/ 100 occupied beds 7 times more integrated pharmacists than clinical pharmacists/100 occupied beds Pedersen CA et al. AJHP 2007; 64:

Staffing 19,1 FTE/100 occupied bed (estimated occ. Rate – 85 %) vs 14 up to 20 FTE/100 occupied bed in USA Johnson N et al. Hospital Pharmacy in Canada

Staffing Johnson N et al. Hospital Pharmacy in Canada

Staffing But we ignore what … –Is the optimal staffing in terms of FTE to fulfill adequately patient needs –Is the optimal ratio pharmacists / non pharmacists –Should be the future role of pharmacy technicians for non dispensing activities –Is the impact of having a non-pharmacist as a head of pharmacy department

Staffing So we have to … –Collect indicators to be able to calculate ratio (# dose dispensed, # patient-days adjusted for case-mix … ) –Agree upon key ratio to be reported at least regionally for benchmarking –Develop indicators for ambulatory/outpatient care activities

Time devoted to clinical pharmacy Only 24 % of respondants devote > 29 % of their time to monitoring medication therapy in US Pedersen CA et al. AJHP 2007; 64:

Time devoted to clinical pharmacy 41 % of pharmacists’ time is devoted to clinical (patient care) activities in Canada Johnson N et al. Hospital Pharmacy in Canada

Time devoted to clinical pharmacy But we ignore what … –Is the optimal % of time of clinical activities for a pharmacy department –Is the optimal % of time for clinical activities of an individual on a daily, weekly, monthly or annual basis –Is the optimal number of clinical specialty per individual (1, 2, more ?)

Time devoted to clinical pharmacy We have to … Agree upon a simple system to capture (bill) the nature of pharmacy services provided by individual on a regular basis Evaluate the optimal mix (clinical/non clinical) for productivity, retenteion and impact of pharmacists

Specialization Outpatient and inpatient pharmacy services OUTPATIENT Hematology-oncology – 80 % Renal/dialysis – 63 % Emergency – 54 % Anticoagulation – 52 % Infectious disease/AIDS – 40 % Diabetes – 39 % Transplantation – 31 % Mental health – 27 % Geriatrics/LTC – 26 % Pain/ palliative care – 26 % Asthma / allergy -16 % General medicine – 14 % General surgery – 14 % Neurology – 13 % Gynecology – obstetrics – 8 % Rehabilitation – 7 % INPATIENT Geriatrics/LTD – 83 % Adult critical care – 79 % Hematology-oncology – 78 % General medicine – 78 % Pain / palliative care – 70 % Cardiovasculair /lipid – 68 % Mental health – 63 % General surgery – 63 % Pediatric /neonatal critical care – 56 % Renal / dialysis – 51 % Rehabiliation - 50 % Hematology/anticoagulation – 46 % Infectious disease/AIDS – 46 % Transplantation – 45 % Gynecology – obstetrics – 43 % Diabetes – 41 % Neurology – 40 % Asthma-allergy – 37 % Johnson N et al. Hospital Pharmacy in Canada

Specialization Outpatient pharmacy services Johnson N et al. Hospital Pharmacy in Canada

Specialization Inpatient pharmacy services Johnson N et al. Hospital Pharmacy in Canada

Effectiveness of hospital pharmacy Litterature search and review Different domains –General medication review and clinical intervention monitoring –Multidisciplinary teamwork –Patient’s own drugs and self-administration schemes –Pre-admission clinics –Patient discharge services –Shared care, primary/secondary care interface and outreach services –Outpatient service –Mental Health –Intensive care units and theatres –Patient counselling and education –Aseptic services –Non-sterile manufacturing –Pain control –Medicines information –Anticoagulant services –Pharmacokinetic and therapeutic drug monitoring services –Extended hours, residency and on-call services –Strategic medicines management, formulary services and clinical audit –Education and training –Renal services –ADR and clinical risk management –Computer support services –Pharmacist prescribing –Pharmacy technicians and ATO’s –Others Guild of healthcare pharmacists. 2001

Effectiveness of hospital pharmacy Guild of healthcare pharmacists articles 13 reference database (Medline, Pharmline, EPIC, etc.) Mainly UK publications No statistical analysis Most studies have positive results (publication biais ?) Authors have identified 7 key concerns

Specialization But we ignore … How to better prioritize a clinical specialty vs another The evidences about the impact of pharmacist per specialty What level of resources should be devoted to a specific specialty How to recognize specialist vs generalist

Specialization But we have to … Monitor published evidences for pharmacy practice as for drug therapy Build business cases for clinical pharmacy with evidences, patients and professionals needs Recognize specialist in pharmacy

Impact of clinical pharmacy Clinical pharmacy can have –A positive impact on costs –A positive impact on adverse drug event, reaction and medication error –A positive impact on lenght of stay –A positive impact on

Economic benefits

Effect of pharmacists’ interventions on patient and process outcomes

343 articles retrieved from but only 36 included Controlled studies, inpatient, patient outcomes –Pharmacists’ participation on medical rounds (n= 10) –Medication reconciliation studies (n=11) –Drug specific services (n=15) Global impact –ADE, ADR or ME were reduced in 7/12 –Medication adherence, knowledge and appropriateness were improved in 7/11 –Shorten lenght of stay in 9/17 –Higher use of healthcare in one study –No studies reported worse clinical outcome

Association between pharmacists, clinical pharmacy and health care outcomes Bond CA et al. Pharmacotherapy 2001; 21 (2): Increasing # pharmacists/100 occupied beds is associated with a reduction in # deaths/hospital/year Increasing # clinical pharmacists/100 occupied beds is associated # deaths/1000 admissions

Association between pharmacists, clinical pharmacy and health care outcomes Bond CA et al. Pharmacotherapy 2001; 21 (2): Increasing # clinical pharmacists is associated with a reduction in LOS

Association between pharmacists, clinical pharmacy and health care outcomes Bond CA et al. Pharmacotherapy 2006; 26 (6);  50 % des ADR/year by increasing the # clinical pharmacists/100 occupied beds from 0,9 à 5,7

Association between pharmacists, clinical pharmacy and health care outcomes Medication errors/occupied bed/year rate is lower –when pharmacists are decentralised (1,74) –or centralized with ward visits (1,93) Vs centralized (3,15)

BEFORE

Prioritization Admission and discharge interviews

Prioritization - Rounds and consultation with physicians and kardex rounds with nurses

Prioritization Pharmacokinetic dosings

AFTER

Average level of service and ranking priority Johnson N et al. Hospital Pharmacy in Canada

Average level of service and ranking priority Johnson N et al. Hospital Pharmacy in Canada

Prescribing

Evaluation Johnson N et al. Hospital Pharmacy in Canada

Prioritization But we ignore … How to prioritize amongst all clinical pharmacy activities How to better delegate or collaborate with other professionals without losing the essence of pharmacy practice How to document and evaluate theses activites

2015 Vision

So what’s next ? Find, read, understand and use evidences Document, benchmark, evaluate and update models, specialty areas, hierarchy of activities Meet, discuss, move towards consensus about pharmacist role to develop an evidence based practice model Question, research, answer, publish and transfer the knowledge within and outside the profession