The Establishment and Outcomes of a Model Primary Care Pharmacy System

Jannet M. Carmichael, Pharm.D., FCCP, BCPS, Autumn A. Alvarez, Pharm.D., Ryan L. Chaput, Pharm.D., Jennifer L. DiMaggio, Pharm.D., Heather E. Magallon, Pharm.D.

VA Sierra Nevada Healthcare System

Reno, Nevada

Rationale and Objective

A primary care pharmacy practice model was established at this government health care facility in March of 1996. The original objective was to establish a primary pharmacy practice model that would demonstrate improved patient outcomes and maximize the pharmacist’s contributions to drug therapy. Since its inception, many improvements have been realized and supported by advanced computer and automated systems, expanded disease state management practices, and unique practitioner and administrative support. This paper will characterize a fundamentally redesigned environment of pharmacy in the primary care teams of this medical center and describe several outcome studies that demonstrate improved quality, access, and cost of patient care.

Description

The model described in this paper is from one medical center in a system of about 1,300 care facilities, including 163 hospitals, 850 ambulatory care and community-based outpatient clinics, 206 counseling centers, 137 nursing homes and 43 domiciliary facilities in the VA system. Due to technology and changes in national and VA health care trends, VA has evolved from a hospital-based system to a primarily outpatient-focused system over the past five years. This VA provides care to 24,000 active patients within an 110,000 square mile geographic area. Pharmacists individually code and document care for approximately 2500 outpatient clinic visits on 1500 patients each month. This has been accomplished with a small and highly trained staff of 23 pharmacists, 14 technicians, and maximal use of available automated systems.

There are currently five primary care teams at this facility; each has one or more Clinical Pharmacy Specialists as full time members of the team. Scheduling of patients is accomplished by referral from primary care and specialty providers to one of the pharmacy clinics. Specific disease-state management issues are addressed in 20 to 30 minute time slots. The primary care team pharmacist has additional responsibilities including counseling patients on new prescriptions, the verification of physician orders, triage of medication related phone calls, and teaching obligations.

The pharmacists work under protocol in a system of Collaborative Drug Therapy Management. Obtaining approval to practice in this manner involves submitting a Scope of Practice document to the Medical Executive Committee. Once approved, the pharmacist may, without co-signature, initiate, modify, continue, and monitor a patient’s drug therapy under approved protocols. The ability to prescribe and practice collaboratively has been essential to the development of this practice site.

The data systems that are available in this practice site facilitate the provision of pharmaceutical care. All patients have an electronic chart that provides for a quick link between the patient’s problem list, medications, consults, orders, labs discharge summaries, reports, and chart notes. Providers enter medication orders, labs, and consults directly into the chart. Drug use criteria are available for hundreds of medications and are readily available on electronic media as well as upon order entry. Over 50 templated chart notes provide a framework for each pharmacy visit, as well as consistency from visit to visit and pharmacist to pharmacist.

An extensive system of automated prescription filling frees the pharmacist and allows for more clinical activities. The outpatient pharmacy utilizes an Autoscript III Robot, Baker cells, and the McKesson APS Pharmacy 2000 system to diminish the risk of errors and to increase efficiency. Consolidated Mail Outpatient Pharmacy, a prescription-filling warehouse located in another state, handles approximately 86% of the mail out prescription refills.

Summary of Outcomes

In the years since the inception of the primary care clinics, many outcome studies have been performed on pharmacist initiated and managed clinics. These studies have led to improved patient care and have conveyed the cost-effective role pharmacists can play as independent practitioners in this environment of patient care. Five recent examples are described in the text of this paper.

The first outcome study described is the result of a primary prevention lipid clinic designed to reduce the ten-year risk of coronary heart disease. Fifty-six primary prevention patients and eight secondary prevention patients were enrolled in the clinic from August 2001 to April 2002. Primary prevention patients were managed to reduce LDL below 130 mg/dl and secondary prevention patients were treated to LDL goal, for high blood pressure, lifestyle modifications, and VA performance measures were assessed. In conclusion, the addition of lipid lowering therapy reduced the risk of long-term cardiovascular complications.

The second outcome study depicts the effect of a pharmacist-managed cardiovascular clinic in patients with diabetes and dyslipidemia from August 2001 to April 2002. Fifty-one patients were initially evaluated in the clinic and 41 returned for a second visit. Patients were managed according to VA performance measures, NCEP III Guidelines, and clinic outcomes (LDL <100 mg/dl or TC/HDL ratio <5.) The results displayed a statistically significant decrease in LDL and TC/HDL levels.

The third outcome study results are derived from a pharmacist-run primary care clinic focused on blood pressure reduction in 44 patients with diabetes from October 2000 to April 2001. The primary objective was to decrease blood pressure to <130/85 mmHg and secondary objectives dealt with adherence to VA recommendations for diabetes indicators. The results showed decreased blood pressure (20% reduction in the intervention group versus 4% reduction in the comparative group) and improved compliance when pharmacists were involved in the management of diabetic patients.

The fourth outcome study described is the result of a cost analysis, which identified inappropriate prescribing of proton pump inhibitors. Patients with active lansoprazole prescriptions were recognized, indications were assessed, and patients without proper indications (n=834) were included in the analysis. Based on the annual cost per patient of lansoprazole, potential medication cost savings of $142,000 per year were projected. Follow up studies have documented $320,000 actual savings on Proton Pump Inhibitors.

The final outcome study detailed in the paper involves pharmacist interventions withy pharmacoeconomic, medical, and quality of life outcomes in a pharmacist-managed H. pylori clinic. Sixty-five patients taking ranitidine were identified and tested for H. pylori. Pharmacists were successful in decreasing medication in 81% of the patients, resulting in a yearly drug cost savings of approximately $20,000. In conclusion, patient quality of life was improved and the hiring of a pharmacist was justified based on expected drug cost savings. Follow-up provided confirmation of these findings.

Conclusions

The development of this pharmacy practice clearly demonstrates a fundamental redesign of pharmacy services. The activities demonstrate cutting edge leadership in health-systems pharmacy that exemplifies the ASHP Best Practices Award. Fundamental redesign has been used to improve consistent access to a medication expert and has significantly improved the quality of patient care while easing physicians’ workload without causing increase in health care costs.