Disease State Management Services Provided by Primary Care Pharmacists in a Community-Based Medical Network

Steven W. Chen, Pharm.D., FASHP, CDM Karine Simonian, Pharm.D., Emmanuel Saltiel, Pharm.D., FASHP, Edith Mirzakhanian, Pharm.D., Stephen Deutsch, M.D., FACP, Delia Vogel, RN, CPHQ

Cedars-Sinai Medical Group

Beverly Hills, California

A recent national survey of ambulatory care pharmacy practices in managed care and integrated health systems indicated that the majority of practice settings (~85%) were health maintenance organizations or hospital-based integrated health care systems. Our practice setting is unique in that it is a medical network located in a metropolitan area comprised of a private medical group and an independent practice association (IPA). In the early 1990’s, the medical director realized that he needed assistance with ensuring optimal use of medications throughout the network. Guidelines for the management of many chronic illnesses indicate that an increasing number of medications are required to meet stringent therapy goals. In the medical network, problem-prone patients (e.g., noncompliant, multiple disease states) were found to utilize a disproportionately large amount of physician and acute care resources. And while the medical network has been able to remain exempt from financial risk for prescribed outpatient medications, over utilization of expensive and unnecessary medications adversely impacts annual contract negotiations with health plans. Consequently, a pharmacy director from an affiliated medical center was consulted and a pharmacist was hired by the medical network in 1994 to initiate an ambulatory care pharmacy program. The overall goal for the ambulatory care pharmacy program was defined as improvement of patient care through the optimal use of medications. Specific objectives identified to meet this goal include the following:

1. Develop pharmacist-run DSM programs for chronic illnesses requiring multiple and/or complicated medications.
2. Create a system for collecting, analyzing, and reporting data reflecting patient outcomes and quality of care provided in the pharmacist-run DSM programs.
3. Conduct medication use evaluations (MUEs) for high cost, high-volume, and/or problem prone medications and formulate solutions for prescribing problems identified.

Over the course of 3 years, several pharmacist-run disease state management (DSM) services were developed including anticoagulation, asthma, dyslipidemia, and hypertension. Additional pharmacist support provided in 2000 resulted in the development of a comprehensive relational database to support documentation of clinical data from all pharmacist-run DSM programs. The database, which required a year and a half to complete, provided the clinical pharmacists with the ability to capture important patient outcome data during clinic time; this was accomplished by integrating the documentation process with the flow of the patient care. Quality improvement reports generated from the database are discussed with the medical director and shared with the medical staff primarily through quarterly disease management meetings and quarterly evening physician education programs. Numerous MUEs were conducted and several uncovered findings that improved quality of patient care.

Clinical data from the anticoagulation and asthma management services serve as specific examples of patient outcomes attained. INR test results are captured by the pharmacy database program and percentage of INR test results within therapeutic range were reported on a semi-annual basis. The proportion of therapeutic INR test results reported are consistently above the established benchmark of 70%. Episodes of hemorrhagic or thrombotic events are rare and not associated with non-therapeutic INR results.

Data from the medical record reviews and the asthma management program (AMP) indicated that while a very high proportion of persistent asthmatics were receiving long-term control medications and acute care utilization by asthmatics was minimal, many patients were overusing short-acting beta-2 agonist inhalers and very few physicians were providing written asthma self-management action plans. AMP service outcomes evaluated were consistent with the four points of the Quality Compass: Clinical (changes in utilization of long-term control medications for patients with persistent asthma), economic (health care utilization), health status (quality of life survey), and patient satisfaction. At the end of the reporting period, the proportion of patients with any level of persistent asthma receiving a long-term control medication was high at 99%, greatly exceeded the established 1 and 2 year goals. All AMP patients who were able to measure their personal best peak flow received a written plan for exacerbation self management. Comparison of health care resource utilization 6 months before vs 6 months after AMP enrollment demonstrated a reduction in office visit frequency by 67%, which exceeded the established goal of a 50% reduction. All patients who completed the quality of life survey demonstrated a significant improvement from baseline, and all patient satisfaction surveys received indicated maximal scores in overall satisfaction with asthma care and only positive comments about the AMP.

The findings and impact of the ambulatory care pharmacy program are disseminated to the medical staff through a variety of methods. QI reports for DSM services are presented by the pharmacists in quarterly disease management committee meetings. In addition, the pharmacists have the opportunity to present QI reports, MUE findings, drug information updates, and disease management guideline information to the entire medical staff at quarterly medical staff business/education meetings. On occasion, memorandums, newsletters, or e-mail may be utilized to communicate with physicians; however, these communication modes are generally less effective and are primarily used to reinforce previously presented materials.

The ambulatory care pharmacy program at our medical network provides valuable services that improve patient care in a relatively unique setting. Having the support of a respected medical director, who is also the founder of the medical network, is immeasurably valuable. However, the DSM services could not be sustained without documentation supporting their value, which is now available through the pharmacist-authored database documentation program. Our practice continues to evolve and new opportunities to improve patient care are in development. These opportunities have resulted in the addition of another full-time pharmacist to the clinical pharmacy staff. All members of the pharmacy planning team firmly believe that ambulatory care pharmacy services are a highly valuable addition to any large medical group practice, particularly with the growing complexity and expense of medication therapy regimens combined with the dramatic growth in the elderly population.