1. Hospital Pharmacy in Canada 2005-2006 Hey Kid … what do you do now ? Jean-François Bussières B Pharm MSc MBA FCSHP Chef, département de pharmacie et unité de recherche en pratique pharmaceutique Professeur agrégé de clinique Faculté de pharmacie, Université de Montréal Membre du comité de rédaction Rapport canadien sur la pharmacie hospitalière

2. 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 ?

4. Who are we ? Response rate = 74 % Teaching institutions = 26 % Johnson N et al. Hospital Pharmacy in Canada 2005-6

5. Who are we ? Please consider absolute numbers … but prefer ratios when available Always understand what’s behind the numbers Johnson N et al. Hospital Pharmacy in Canada 2005-6

7. 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

8. Clinical practice models Traditional (89 %) and pharmaceutical care (82 %) are largely implemented Pharmacy departments use both models and an important % or beds are still non covered Johnson N et al. Hospital Pharmacy in Canada 2005-6

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

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

11. 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

12. 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

13. 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

14. A new entry-level Pharm. D.

15. 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

17. 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: 937-44.

18. Staffing 15 FTE pharmacists/ 100 occupied beds 7 times more integrated pharmacists than clinical pharmacists/100 occupied beds Pedersen CA et al. AJHP 2007; 64: 507-20.

19. Staffing 19,1 FTE/100 occupied bed (estimated occ. Rate – 85 %) vs 14 up to 20 FTE/100 occupied bed in USA Johnson N et al. Hospital Pharmacy in Canada 2005-6

20. Staffing Johnson N et al. Hospital Pharmacy in Canada 2005-6

21. 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

22. 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

23. Time devoted to clinical pharmacy Only 24 % of respondants devote > 29 % of their time to monitoring medication therapy in US Pedersen CA et al. AJHP 2007; 64: 507-20.

24. Time devoted to clinical pharmacy 41 % of pharmacists’ time is devoted to clinical (patient care) activities in Canada Johnson N et al. Hospital Pharmacy in Canada 2005-6

25. 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 ?)

26. 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

27. Specialization Outpatient and inpatient pharmacy services OUTPATIENT Hematology-oncology – 80 % Renal/dialysis – 63 % Emergency – 54 % Anticoagulation – 52 % Infectious disease/AIDS – 40 % Diabetes – 39 % Transplantation – 31 % Mental health – 27 % Geriatrics/LTC – 26 % Pain/ palliative care – 26 % Asthma / allergy -16 % General medicine – 14 % General surgery – 14 % Neurology – 13 % Gynecology – obstetrics – 8 % Rehabilitation – 7 % INPATIENT Geriatrics/LTD – 83 % Adult critical care – 79 % Hematology-oncology – 78 % General medicine – 78 % Pain / palliative care – 70 % Cardiovasculair /lipid – 68 % Mental health – 63 % General surgery – 63 % Pediatric /neonatal critical care – 56 % Renal / dialysis – 51 % Rehabiliation - 50 % Hematology/anticoagulation – 46 % Infectious disease/AIDS – 46 % Transplantation – 45 % Gynecology – obstetrics – 43 % Diabetes – 41 % Neurology – 40 % Asthma-allergy – 37 % Johnson N et al. Hospital Pharmacy in Canada 2005-6

28. Specialization Outpatient pharmacy services Johnson N et al. Hospital Pharmacy in Canada 2005-6

29. Specialization Inpatient pharmacy services Johnson N et al. Hospital Pharmacy in Canada 2005-6

33. 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

34. Effectiveness of hospital pharmacy Guild of healthcare pharmacists. 2001 10 099 articles 13 reference database (Medline, Pharmline, EPIC, etc.) Mainly UK publications No statistical analysis Most studies have positive results (publication biais ?) Authors have identified 7 key concerns

35. 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

36. 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

37. 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

38. Economic benefits

41. Effect of pharmacists’ interventions on patient and process outcomes

42. 343 articles retrieved from 1985-2003 but only 36 included Controlled studies, inpatient, patient outcomes –Pharmacists’ participation on medical rounds (n= 10) –Medication reconciliation studies (n=11) –Drug specific services (n=15) Global impact –ADE, ADR or ME were reduced in 7/12 –Medication adherence, knowledge and appropriateness were improved in 7/11 –Shorten lenght of stay in 9/17 –Higher use of healthcare in one study –No studies reported worse clinical outcome

47. Association between pharmacists, clinical pharmacy and health care outcomes Bond CA et al. Pharmacotherapy 2001; 21 (2): 129-41. 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

48. Association between pharmacists, clinical pharmacy and health care outcomes Bond CA et al. Pharmacotherapy 2001; 21 (2): 129-41. Increasing # clinical pharmacists is associated with a reduction in LOS

49. Association between pharmacists, clinical pharmacy and health care outcomes Bond CA et al. Pharmacotherapy 2006; 26 (6); 735-47  50 % des ADR/year by increasing the # clinical pharmacists/100 occupied beds from 0,9 à 5,7

50. 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)

51. BEFORE

52. Prioritization Admission and discharge interviews

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

54. Prioritization Pharmacokinetic dosings

55. AFTER

56. Average level of service and ranking priority Johnson N et al. Hospital Pharmacy in Canada 2005-6

57. Average level of service and ranking priority Johnson N et al. Hospital Pharmacy in Canada 2005-6

59. Prescribing

60. Evaluation Johnson N et al. Hospital Pharmacy in Canada 2005-6

61. 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

62. 2015 Vision

63. 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