Existing Pharmacy Practice:

Problems and its Consequences

 Presentation, objectives
 To review problems in the existing Pharmacy practice

 To high light the Consequences of the existing Pharmacy

Practice
 To discuss the rational of clinical pharmacy services

 Describe the clinical and economical benefit of Clinical

Pharmacy Services

 To recommend on package of Clinical Pharmacy Services

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 Old paradigm Pharmacy Practice: Problems

1. Knowledge and skill gaps of the professionals

Lack of knowledge of disease state pathophysiology

Lack of knowledge/skills required;

 To collect and interpret patient specific data,
 To take medication related histories
 To identify drug- therapy related problems.

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 Problems….cont’d

Pharmacists know more the product but they know

little about their patient.

Disease condition , co morbidities

Patient medication histories
Organ function

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 Problems….cont’d
Lack of communication skills to effectively
communicate with patient ,caregivers and
physician.

More knowledge of drug product but few patient

information.
Fear of Pharmacist- physician interaction

Fail to recognize themselves as member of the

health care team

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 Problems….cont’d

Lack of recognition of pharmacists by

physician as member of health care team

Little acceptance of pharmacists’

recommendation by physician

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 Problems….cont’d

Most drug therapy decisions are made by the

physician

leaving the pharmacist’s role more reactive; i.e.,

responding to prescribing errors long after the
decision has been made, and without having
direct clinical knowledge of the patient.

 This leads to inappropriate or contraindicated

prescriptions that remain undetected by
pharmacists.
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 Problems….cont’d

If pharmacist able to detect any prescribing error,

 Patient suffer more due to lack of pharmacist–

physician interaction.

 This leads to lack of confident by the patient on the

professionals

 This will have negative impact on treatment

outcomes
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 What could be a solution?
• Pharmacists should move from behind the counter
and start serving the public by providing care instead
of pills only.

• There is no future in the mere act of dispensing.

These technical services are still fundamental to the
current service and should become increasingly
specialized and complemented by a wide variety of
ward-based, patient-focused activities.

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 What could be a solution?
• There should be paradigm shift in pharmacy practice:
Pharmaceutical care (focus on patient care) than
product based practice.

Fill the existing gap in Patient Care

 Medical Care
 Nursing Care
 Pharmaceutical Care ???

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 Strategies( Filling skill gaps)
 To implement patient focused pharmacy training
(Under graduate patient – focused pharmacy training)

 In-service Clinical Pharmacy training for hospital

pharmacists (to fill gaps in Hospital Clinical Pharmacy
Services)

Advanced patient focused pharmacy training (Postgraduate

training in Clinical Pharmacy)

 Post graduate diploma certificate in clinical Pharmacy

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 Principles and Benefits of Clinical
Pharmacy Practice

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 Clinical Pharmacy activities
• There is a wide range of clinical pharmacy activities
performed throughout the world, which include, but are not
limited to

• Patient medication review, selection of drug therapy ,

Ward rounds, Therapeutic drug monitoring, Drug
information, Medication reconciliation, In service
education, medication counseling, taking medication
histories, drug utilization evaluations, adverse drug
reaction (ADR) management, clinical research, and
participation in specialty teams

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 Clinical Pharmacy activities

• In many developing countries, clinical pharmacy services are

still in their infancy
• However, the development of clinical services is well
established in developed countries
• Pharmacists in Japan previously spent a great deal of time
in manufacturing of products, but recently, approximately
50% of inpatients received clinical services on the wards
• Australia - 41% of the pharmacists’ time was spent in
clinical activities

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 Sample Clinical Pharmacy Services

Country Sample Clinical Pharmacy services

Canada • increasing participation in ward rounds, admission
histories, pt. group teaching, clinical drug trial services,
pharmacokinetic dosing
Denmark • drug information, increasing ward rounds and interaction
with ward personnel
Germany • Pharmacokinetics dosing, drug information, ward rounds,
patient counseling, clinical trails

Ireland • 30% of pharmacists provide CPS, patient counseling, drug

information, attendance at wards

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 Sample Clinical Pharmacy Services

Country Sample Clinical Pharmacy services

India • increasing clinical activities including ward rounds, drug
information services, and ADR monitoring and reporting

Lebanon • provide pharmaceutical care, especially in large centers

New Zealand • daily visits to wards
South Africa • attend clinical ward rounds, TDM, pt oriented services in some
hospitals

UK • ward based activities is standard practice, pharmacists attend

ward rounds

Zimbabwe • ward rounds in 2 central hospitals, some pharmacokinetic

consults

Ghana • large teaching hospital ward based service is well developed,

drug information, pt counseling

J M LeBlanc and JF Dasta. Scope of International Hospital Pharmacy Practice. The Annals of
5/22/2022
Pharmacotherapy 2005 January, Volume 39 16
 Australia
• SHPA declares that all patients should receive clinical pharmacy
services as part of routine care
• based on a study of the impact of pharmacists in 8 Australian
teaching hospitals that documented the clinical impact of
pharmacist-initiated drug therapy
• Pharmacists playing a major role in primary health care
• Primary health care is central to health care provision for the
pharmacist
• A number of pharmacists employed within the hospital department
are allocated to work fulltime on the ward as a member of the health
care team
• The role of clinical pharmacists is defined as a multidisciplinary team
member working to optimize QUM for patients

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 The United Kingdom
• Professional Standards For Hospital Pharmacy Services: Optimizing patient
outcomes from medicines [July, 2012]
• On admission or at first contact
• Patients’ medicines are reviewed; to ensure an accurate medication
history, for clinical appropriateness and to identify patients in need of
further pharmacy support
• Medication reconciliation should be offered within 24 hrs. of admission
• Operational leadership
• Pharmacy services are patient centered, and aligned with organizational
priorities and the range and level of healthcare commissioned/purchased
• Care as an inpatient
• Patients have their medicines reviewed by a clinical pharmacist to
ensure that their medicines are clinically appropriate, and to
optimize their outcomes from their medicines

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 UK….
• Pharmacists attend relevant multidisciplinary ward rounds
and/or case reviews
• Patients, medical and nursing teams have access to pharmacy
expertise when needed
• Pharmacists work closely with patients and other health
professionals to reach a joint decision on which treatment
option best suits an individual patient’s needs
• Pharmacists are integrated into clinical teams across the
organization and provide clinical care direct to patients

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 The Clinical and Economic Value of Clinical
Pharmacy Services
• Clinical Pharmacy Services result in measurable, reproducible
value to the patient, other patient care providers, the payer,
and the health care system in general
– have been shown to decrease medical costs, improve clinical
outcomes, and have significant impact on the appropriateness,
effectiveness, safety, and compliance with medications
– The ROI of medication management services has been
established….the results are positive, with a demonstrated ROI of as
high as 12:1 and an average of 3:1 to 5:1
– ROI reflects an ability to decrease hospital admissions, physician visits,
and emergency room admissions and reduce the use of unnecessary
and inappropriate medications

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 The Clinical Value to the Patient

• In a Minnesota data: high-risk Medical population involving

1651 patients who were seen during 4453 encounters
– The percentage of medical conditions at goal changed from 54% at
baseline to 80% with the service, and an average savings of $1594 per
patient and $2,729,424 in total cost savings were realized as a result of
identifying and resolving drug therapy problems
– Demonstrated a 12:1 ROI when the service was delivered by qualified
providers (trained clinical pharmacists) in a commercial insurance
population resulting in a $3768 (31.5%) decrease in costs per patient
in one year
– Clinical goals of therapy improved from a baseline of 76% to 90% with
an average of 2.2 drug therapy problems identified and resolved per
patient

Isetts BJ, Schondelmeyer SW, Artz MB, et al. Clinical and economic outcomes of medication therapy
management
5/22/2022 services: the Minnesota experience. J Am Pharm Assoc. 2008;48(2):203–211 21
 The Clinical Value to the Patient

• Decreased
– Adverse drug events
– Adverse medication reactions
– Medication errors
• Improved
– Medication adherence
– Drug knowledge
– Appropriate medication use
– Attainment of goal of therapy
• Shortened length of hospital stay

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 The Clinical Value to the Patient
• In one study:
– As clinical pharmacist staffing increased from 0.34/100
occupied beds to 3.23/100 occupied beds , mean length
of hospital stay fell from 10.17 to 5.39 days/patient…a
47% reduction
• Hospital deaths declined from 113/1000 to 64/1000 admissions
(43% decline)
– The number of clinical pharmacists/occupied bed tended
to have the greatest association (slope) with reductions in
length of hospital stay
– It was the best predictor of all pharmacy variables for
shorter length of hospital stay in study hospitals

C. A. Bond et al. Interrelationships among mortality rates, drug costs, total cost of care, and Length of Stay
in United States Hospitals: Summary and Recommendations for Clinical Pharmacy Services and Staffing.
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Pharmacotherapy. 2001;21(2)
 Conclusion: studies

• Increased staffing levels of clinical pharmacists were

associated with improvements in all four heath care outcome
measures- mortality rates, drug costs, total Cost of care, and
length of hospital stay

• The number of clinical pharmacists/occupied bed tended to

have the greatest association with reductions in mortality
rate, drug costs, and length of hospital stay
• The best way to improve patient care and reduce costs is to
increase staffing levels of clinical pharmacists and promote
clinical pharmacy services that these pharmacists perform

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 Hospital Pharmaceutical Services Minimum requirements
( FMHACA)
Clinical Pharmacy Services:
The hospital DTC shall establish policies and
procedures for the provision of clinical pharmacy
services

Depending on the number of beds available and

convenience for service delivery, the hospital shall
have inpatient pharmacy or ward pharmacies
each managed by a licensed clinical pharmacist or
a licensed pharmacist trained on clinical
pharmacy practice.

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 Hospital Pharmaceutical Services Minimum
requirements ( FMHACA)

Clinical Pharmacy Services:

 Patient-specific medication therapy information must
be evaluated and a medicine therapy plan shall be
developed by the pharmacist mutually with the
patient, the prescriber and nurse.
 The pharmacist shall review, monitor and propose for
modification of the therapeutic plan in case of
adverse effects, patient noncompliance, evidence-
based efficacy problem and as appropriate, in
consultation with the patient, prescriber and nurse.
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 Hospital Pharmaceutical Services Minimum requirements
( FMHACA)

Clinical Pharmacy Services:

 The processes of prescribing, dispensing and

administering medicines are inherently risk-laden and
hence the clinical pharmacy services shall take
responsibility for ensuring safe, appropriate and
effective use of medicines (minimizing risk) at all
stages of the patient medication journey.

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 Hospital Pharmaceutical Services Minimum requirements
( FMHACA)

Clinical Pharmacy Services:

 As a member of the health care team, the pharmacist

shall attend and participate at multidisciplinary ward
rounds/morning meetings and contribute to patient
care through the provision of medicine information,
dose calculations and adjustment, assisting in the
rational prescribing decision, alternative regimens
and reducing the frequency and duration of
medication errors.
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 Clinical Pharmacy Services

The clinical pharmacist join the health care team with

unique responsibilities.

So the practice of clinical pharmacy is not to replace

any profession but to fill the existing gap in Patient
Care
Medical Care
Nursing Care
Pharmaceutical Care

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Pharmaceutical Care
 THE CHANGING ROLE OF THE PHARMACIST

DISPENSING PHARMACY PHARMACEUTICAL CARE

• Product business • Service (people) business

• Bring the product to • Bring the practitioner to
consumer patient
• Decisions focus on the • Decisions focus on the
business patient
• Inventory generates • Patient care generates
revenue revenue
• Available service • Available products
supports products support service
DISPENSING PHARMACY PHARMACEUTICAL CARE

• Success measured as # of • Success measured as

Rx patient outcomes
• Space to display and sell • Space organized to meet
• Records kept for legal patient needs
purposes • Documentation to
• Visits determined by refill provide quality care
supply • Visits determined by
• Business passive via patient risk/benefit
prescriptions • Practice grows via patient
recruitment
 Pharmaceutical Care in Health Care
Primary Knowledge Responsibility in
the drug use
Focus Base process
Diagnosis and
Medical
treatment of the Pathophysiology Prescribing
Care
patient’s disease
Giving care to the Biological,
Nursing whole patient psychological, Drug
Care during the cure or social, or spiritual administration
treatment human responses
Identification,
Identifying and prevention, and
Pharmaceu
meeting a patient’s Pharmacotherapy resolution of
-tical Care
drug-related needs drug therapy
problems
 Defining Pharmaceutical Care

• Pharmaceutical care is a patient-centered practice

in which the practitioner assumes responsibility
for a patient’s drug-related needs and is held
accountable for this commitment.
• Pharmaceutical care is how a practitioner applies
expert pharmacotherapeutic knowledge in
practice to benefit the patient.
 DRUG-RELATED NEEDS

During a pharmaceutical care encounter, the

patient, the patient’s medical conditions, and
all of his/her drug therapies are assessed to
determine if the following drug-related needs
are being met:
 DRUG-RELATED NEEDS
1. The medication is appropriately indicated
 There is a clinical indication for each
medication being taken.
 All the medication that is needed to treat
each of the patient’s medical conditions
is being taken.
 DRUG-RELATED NEEDS
2. The medication is effective
–The most effective product is being used.
–The dose of the medication is achieving
the intended goals of therapy.
 DRUG-RELATED NEEDS
3. The medication is safe
There are no adverse reactions being
experienced.

There are no signs of toxicity.

 DRUG-RELATED NEEDS

4. The patient is compliant

• The patient is able and willing to take the
medications that have been determined to
be appropriate, effective, and safe for the
patient.
 DRUG THERAPY PROBLEMS
• Drug therapy problems are undesirable
events or risks that the patient experiences
that inhibit or delay him/her from achieving
the desired goals of therapy.
• The identification, resolution, and
prevention of drug therapy problems are the
heart and soul of pharmaceutical care
practice
 Thank you !!

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