The Establishment and Outcomes of a Model Primary Care
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
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.
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
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.
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.