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Clinical pharmacy Education : overview and scope of practice Mohammed A B.pharm, Msc.clinpharm Clinical pharmacist Jigjiga University mohzum@hotmail.com Mohammed A
Outline • Overview of Clinical Pharmacy • Global Perspective of Clinical Pharmacy Services • Impact of clinical pharmacy services in the health care system • Draw backs of the present pharmacy practice in Ethiopia • Rationale for Shifting pharmacy practice to Clinical in Ethiopia • Initiatives towards implementing Clinical Pharmacy Service in Ethiopia • Future directions Mohammed A
Overview of Clinical Pharmacy • “That area of pharmacy concerned with the science and practice of rational medication use” • Discipline in which pharmacists provide patient carethat optimizes medication therapyand promotes health, wellness and disease prevention. • It combine caring orientation with specialized therapeutic knowledge, experience, and judgment for the purpose of ensuring optimal patient outcomes. • The practice embraces the philosophy of pharmaceutical care ACCP Mohammed A
Overview of Clinical Pharmacy… • Is the new term introduced in recent years. in contrast to what pharmacists have been doing for years. “Pharmaceutical care is the responsible provision of drug therapy for the purpose of achievingdefinite outcomes that improve or maintain patient’s quality of life” (Hepler and Strand, 1990) & 1999 FIP preventing a disease elimination or reduction of a patients Sx arresting or slowing of a disease process cure of a disease Mohammed A
Overview of Clinical Pharmacy… • Accordingly, the policy sees pharmacists as a member of the healthcare team • From a compounder of pharmaceutical products to a provider of services and information and • Ultimately that of a provider of patient care. Mohammed A
Overview of Clinical Pharmacy… Clinical pharmacists primary work is • to interact with the health care team, • interview and assess patients, • Make specific therapeutic recommendations, • monitor patient responses to drug therapy and • provide medicines information. provide patient-oriented rather than product-oriented services Mohammed A
Overview of Clinical Pharmacy… Clinical pharmacy requires • An Expert knowledge of therapeutics • A good understanding of disease process • Knowledge of pharmaceutical products • Drug monitoring skills • Provision of drug information • Strong Communication skills with solid knowledge of the medical terminology • therapeutic planning skills and • the ability to assess and interpret physical and laboratory findings. Mohammed A
Global Perspective of Clinical PharmacyDeveloped Countries • In the last 4 decades the trend in the pharmacy practice moved from medicine supply more inclusive patient care • Pharmacistsroleevolved fromcompounder, supplier of pharmaceuticals a provider of services, info & patient care. • Practicing Pharmacists tasks are to ensure pts drug therapy is appropriately indicated the mosteffective meds areavailable for pts and Safest possible and convenient for pts Unique contribution for : DT outcome and pts Quality of life Mohammed A
Global Perspective of Clinical PharmacyDeveloped Countries • US and Iran: early 1960s: Pharm D • US: 2000Pharm.Dmandatory for Pharmacy Schools Other continents: • Asia: India: Pharm.D: 2007 • Africa: Egypt: Alexandria University • South Africa, Zambia: baccalaureate degree + internship in clinical areas • UK, Australia, Malaysia, KSA, Jordan,Palastine: M.clinpharm (MSc Clinical Pharmacy) Mohammed A
Global Perspective of Clinical PharmacyDeveloped Countries • curriculum shift and economic transitions continue toreshape the practice of pharmacy/scope. (detection, resolution and prevention of DTPs). Through implementation of clinical pharmacy services 85% EU hospitals some form CPS implemented. • To date, clinical pharmacy services are implemented wellat different levels of hospitals in many developed countries • In some countries, this is no longer an exception but a rule • The pharmacists are considered a knowledgeable drug expert and skilled, persuasivecommunicator and not a pill counter. These pharmacist embraced a new practice model – PC. Mohammed A
Clinical Pharmacy services: perspective in Africa • Pharmacy education (especially content) varies widely • Most pharmacy schools widely use traditional curricula(limited resources), (SA, Ghnna, Keyna, Egypt) • Scarcity of pharmacistsmay detract from training pharmacists in clinical pharmacy provided by academic institutions. • majority working in Business • fewer learning opportunities in clinical pharmacy • Although the relative need is greater. • Unfavorablecompensation packages and working conditions Mohammed A
Clinical Pharmacy services: perspective in Africa • ‘pharmacists in Africa have not fully adopted a new practice philosophy. • Practice still focuses on traditional dispensing and distribution • Probably a combination of inadequate Resources (easy to fix) Knowledge (easy to fix) Skills (easy to fix) Attitude (hard to fix) Mohammed A
Why clinical pharmacy services for the health care system???? Mohammed A
Impact of clinical pharmacy services • During the last 25 years, pharmacists participating in team-based care models in acute care or outpatient clinic settings have made positive contributions to patient care quality and safe meds use improved health and economic outcomes, reduced meds related ADE, morbidity and mortality. • Literatures show that the presence of clinical pharmacists in inpatient wards dec common DTPs, improve patient outcomes and has Economicbenefits • impact of clinical pharmacy services in in-patient setting well documented. 1970s and 1980s Mohammed A
Impact of clinical pharmacy services • Direct pharmacist involvement and proper CPS implementation in a variety of settings : reduce Crisis in health care funding, cost of Rx, saving hospitals money drastically improve medication therapy outcomes. ‘’ A pharmacist who is unable or unwilling to adapt to a new role places millions/billions of money at loss’’. Mohammed A
CPS impact…Rx costs Impact of CPS on Rx costs : USA 1. A US $100 million/ year health care system costs saved adequately trained Pharmacistsclinical intervention in community pharmacy (Benrimoj et al. Economic impact of increased clinical intervention in community pharmacy. Pharmacoeconomics2000Nov;18(5):459–68.) 2. Provision of PCambulatory care; $45.6 billion (in 1995 U.S. dollars) in direct health care costs would be avoided. Johnson et al.Drug-related morbidity and mortality: a cost-of-illness model. Arch Intern Med 1995;155:1949–56. Mohammed A
CPS impact…Rx costs 3. consultantpharmacistsin nursing facilities Bootman et al. The health care cost of drug related morbidity and mortality innursing facilities . Arch Intern Med 1997;157:2089–96 • costof DRPs decreased from an estimated $235 without consultant pharmacists to $162 with consultant pharmacists • total costof managingdrug-relatedmorbidity and mortalitywas $6.64 billion with consultant pharmacists and $9.64 billion without consultant pharmacists. Mohammed A
CPS impact… Rx costs Australia • reported that the annualized cost-savings associatedwith economically measured resources due to pharmacists’ interventions was $4, 447 947 (AUS) in the 8 institutions; • $23 were saved for every $1 spent on a pharmacist to initiate an intervention.Dooley et al. Br J Clin Pharmacol2004;57:513-21. Spain • A hospital in Spain reported pharmacist interventions regarding antibiotic prophylaxis, PK, thromboembolism prophylaxis, and others were associated with a cost-savings of 129, 059 over a 6-month period.Galindo et al. Pharm World Sci2003;25:56-64. Mohammed A
CPS impact… Rx costs Canada • In Canada, the addition of a clinical pharmacist to an ICU resulted in pharmacist-initiated consultations leading to an annualized cost-savings of approximately $67, 665 (CAN) in 1994. Malaysia • The introduction of a part-time pharmacist into the ICU in Malaysia resulted in savings of $4,014 (US) over one month. Mohammed A
CPS impact… Health outcome • pharmacist-initiated drug therapy has Clinical impact 8 teaching hospitals in Australia. Dooley et al. Br J Clin Pharmacol 2004 ;57:513-21. Of all the interventions made • 25% were of major significance (preventing or addressing very serious DRPs). • 38% were of moderate significance (prevented major temporary injury, enhanced the effectiveness of DT, or produced minor decs in patient morbidity or a <20% chance of noticed effect), and • 30.4% were of minor significance (small adjustments and optimizations of therapy). • 1% of the interventions documented were life-saving. Mohammed A
CPS impact… Health outcome Evidences from Hospital - Based studies in Africa • In some African countries there have been major changesin the provision of PC services inhospitals. • Hospital pharmacists made a significant contribution to the reduction of meds errors and work to scale up the safe, effective and economic use of meds. • The most frequent clinical pharmacists’ interventions and contributions were related to general information (42.9%), the addition of new drugs (13.4%) and dose adjustments (12.6%). Mohammed A
What is wrong with the current pharmacy practice in Ethiopia? Mohammed A
Drawbacks of the current/Old practice in Ethiopia • Pharmacists in practice know more about the productbut have little info about their patients. Provide meds they know for patients they do not know • Not well trained in clinical sciences/ Pathophysiology curriculum • Not well trained/lack skills • To collect and interpretpatient specific data, • To take medication related histories • To identify drug- therapy related problems./DTPs Mohammed A
Current/old Practice… Other possible reasons • Lack of effective communicationwith patient ,caregivers and physicians. • Less frequent /no Pharmacists- physicians interaction • Pharmacists in practice fail to recognize themselves as member of the health care team. More to wards business • pharmacists’ recommendationsAcceptance issues??? multifactorial: Mohammed A
Current/old Practice… • Most drug therapy decisions are made by physicians • pharmacist’s role more reactive; (responding to prescribing errors long afterthe decision has been made, and without having direct clinical knowledge of the patient). • EvenIf pharmacists able to detect any meds error, Patient suffer more till the decision is made by the two parties. • Patients loss of trust on the professionals/services • negative impact on Rxoutcomes Mohammed A
Do we need to change Pharmacy Education? (Ethiopia) Mohammed A
Cont… • In our country, Pharmacists are expertin most pharmacy specialties………….is this enough? Our patients, clinicians and the health care systemlackPC We need to apply the knowledge to patient care (direct patient care involvement) all disciplines must become involved with and partly accountable for the whole process. • The pharmacy services should Fill the existing gap in Patient Care; it is Not a Qs competition at all. neither its about propagandas. • Medical Care • Nursing Care • Pharmaceutical Care ??? • There is no future in the mere act of dispensing. it is still essential in the new services philosophy should be complemented by a wide variety of ward-based, community based patient-focusedPC services and researches. Mohammed A
Cont… • Ethiopian Pharmacists should also • move from behind the counter and • reshape the practice by providing care instead of pills only. • We need a paradigm shift in the scope of pharmacy practice in Ethiopia: from product PC ‘’Pharmacists already in practice were mainly trained on the basis of the old curriculum of product focus’’ • If these pharmacists are to contribute effectively to the new patient centered PC practice, they must acquire the new knowledge and skills required for their new role (PC). Mohammed A
Rationale for Shifting pharmacy practiceto Clinical in Ethiopia • Pharmacy profession around the world has made a shiftin terms of education and scope of practice • From lab-based to practical or clinical based. • From technical aspect to professional aspect of pharmacy • Are not we behind > 20 yearsfrom the rest of the world CPS? Mohammed A
Rationale …why now??? • Major medicine-treatable diseases is increasing. wide opportunities for PC . • Prevalence of non-communicable diseases is increasing DM, HTN, CVD, RF,Malignancyies, chronic illnesses. Complexity of the mgt, DDI, ADE, monitoring,, New meds demand to meds expert is clear • Major issues with meds access, quality, and rational use lack of communication b/nthe ward teams and pharmacies pharmacists must assume responsibility to prevent these meds reachingthe clinicians and patients. • Existing skillsshould be upgraded and linked to cope up with demand Mohammed A
Rationale … Evidences from our hospital • A study done in JUSH Medical ward found that the prevalence of DRPs to be 73.5% among 257 study participants. Bereket et al ,2011 Of all the DTPS identified, • 103(32.6%) of the DTPs were need additional drug therapy • high dosage 49(15.5%). • Unnecessary drug therapy 49(14.9%), • low dosage 44(13.9%) and • ineffective drug therapy 42(13.3%) . Mohammed A
Rationale … • Another study done in JUSH among outpatients receiving cardiovascular medications found that the frequency of potential DDIs to be 241 (72.6%). Legese et al,2011 Of all the potential DDIs identified, • 200 (67.3%) were of "moderate" severity and • 164 (55.2%) were delayed in on set. Mohammed A
Rationale … • A study done in JUSH ICU indicated that, the Prevalence of medication prescribing errors 209 (52.5%) and administration errors were and 621 (51.8%). Asrat et al,2011 • Of these identified prescribing errors • wrong combination (25.7%), • wrong frequency (15.5%) and • wrong dose (15.1%). • Medication errors associated with antibiotics took the lion's share in both medication prescribing (32.5%) and administration (36.7%) errors. Mohammed A
Rationale … A study done in JUSH among 339 women on ANC follow up showed that 236(69.6%) of the women used meds w/o prescribers order. And only3 women prescribed FA Mohammed et al, 2012 Of all these medications used during pregnancy • 191(56.3%) cat-C followed by • 165(48.7%) cat-B • 57(16.8%) Category-D • 24(7.1%) Category-X Mohammed A
What has been done towards implementing Clinical Pharmacy Service in Ethiopia Mohammed A
Initiatives in Ethiopia • Curricular revision 2008: nationwide • Pharmacy undergraduate curriculum: more patient oriented (4 years + 1 internship) • More than 40% of courses under new patient oriented curriculum are clinical pharmacy courses • Advanced patient focused Postgraduate pharmacy training MSC in Clinical Pharmacy JU Since 2008 MSC in Pharmacy practice AAU Since 2010 • In-service Clinical Pharmacy training for hospital pharmacists. JU, 2012 Mohammed A
The Focus of the New Pharmacy Curriculum What do students mainly focus on ???? • Clinical Application of Drug Therapy • Disease state knowledge • Treatment guidelines and literature evaluations and comparisons. For clinical use • Diagnostic procedures (to identify a drug problem) • Monitoringparameters(lab, PE, other diagnostic tools) to follow safety of drug therapy. Mohammed A
Goal of the new curriculum The goal of Clinical oriented Training • To make future Pharmacists experts in: • identifying and solvingDTPs • becoming patient educators within their scope • selecting the most effective therapy • monitoring the outcome of drug therapy • And highly involved in clinical practice and make better contribution to patients Rx outcome Provider of PC in a wider of settings Mohammed A
PC in Ethiopia • FMoH: EHRIG May 2010 Mohammed A
EHRIG …Clinical Pharmacy Services Window of opportunity for pharmacists • The hospital has policies and procedures for identifying and managing drug use problems, including: monitoringADR, prescription monitoring and drug utilization monitoring.(Operational standard 7) Mohammed A
EHRIG …Clinical Pharmacy Services Clearly state Clinical pharmacy Services as • patient-oriented services developed to promote the rational use of medicines, and more specifically, to maximize therapeutic benefits (optimize Rx outcomes), • minimize risk, reduce cost, and support patient choice and decisions there by ensuring the safe, effective and economic use of drug Rx in individual patients. Mohammed A
EHRIG …Clinical Pharmacy Services • clinical pharmacists should • get information on medication histories, • perform medication reviews, • attend ward rounds, • provide recommendations on drug selection and follow-up, • provide counseling to patients and health care providers. Mohammed A
EHRIG …Clinical Pharmacy Services As member of the health care team, Clinical pharmacists will have the following functions: • Provide advice to • doctors, nurses and other health care workers on the clinical use of Medicines, economic drug utilization and safety, • hospital managers, including clinical managers to enable them to make informed decision with respect to medicines policy, procedures and guidelines • Offer direct patient care services through medication history-taking, medicines education and advice, and Mohammed A
Future directions of our Practice Mohammed A
What is the fate of the “old model? The old “Physicians Prescribe and Pharmacists Dispense” model is no longer fully appropriate to ensure • reduceDTPs, safety, effectiveness and adherence to drug therapy. • prescriber was accountable for the results of pharmacotherapy. (pharmacists were not responsible directly to patients for the cost, quality and results of PC) • Health care costs: meds errors associated hospitalization, physicians visits, lab, mgt • More than 50% of all prescriptions are incorrect • >50% of the people fail to take their meds • ADR: 4%–10% of all hospitalized patients. Developed countries 4th–6th leading cause of death in the USA cost up to US$130 billion a year USA. £466 million in the UK Mohammed A
