Clinical Pharmacists Help Optimize Medication Use

By Annette M. Boyle

HONOLULU — A pilot program at Tripler Army Medical Center that manages patients taking multiple drugs appears poised to post a financial return on investment of 5:1. As a result, the Army plans to expand the program systemwide to achieve a ratio of one clinical pharmacist for every 6,500 prime enrollees.

The program embeds clinical pharmacists in the patient-centered medical home team to optimize medication use and recommend effective treatment options. The pharmacists are considered clinical staff and may receive referrals from providers as part of a wellness check-up, if they are not adhering to their medication regimens, have diabetes or hyperlipidemia, adverse effects or take high-risk medications.

Pfc. Chestley Davies, pharmacy specialist at the Outpatient Pharmacy at Tripler Army Medical Center,  counts capsules as she helps fill a prescription earlier this year.  Army photo

Pfc. Chestley Davies, pharmacy specialist at the Outpatient Pharmacy at Tripler Army Medical Center, counts capsules as she helps fill a prescription earlier this year. Army photo

“Almost any patient can benefit from consulting with a clinical pharmacist, particularly those who meet the Army definition of, polypharmacy such as those on multiple opioids or central nervous system drugs with overlapping toxicities or those who have chronic diseases that require multiple medications to treat,” said Brian White, PharmD, assistant chief of Tripler’s pharmacy department.

Even patients who take herbal supplements could benefit from consultation with a clinical pharmacist, White added. To illustrate the advantages, he told the story of a patient who took the medications prescribed at discharge to resolve a septic infection and landed back in the intensive care unit. A clinical pharmacist realized that the drug interacted with a magnesium supplement the patient took at home and disrupted his kidney function.

“The chief benefits are in quality of care and costs,” noted Lt. Col. Mark Maneval, BSPharm, PhD, assistant chief of operations at Tripler’s pharmacy department. “Anecdotal comments indicate a reduction in emergency room utilization, and we expect to see benefits in health outcomes, particularly in chronic diseases, though improving those conditions typically shows lags of more than a year.”

Many patients gain from the involvement of a clinical pharmacist, even in the short term. In one case, a geriatric patient was discharged from the hospital with a number of medications, but a clinical pharmacist determined he still had some of the same drugs at home so was taking double the appropriate dose, said Col. John Spain, PharmD, MA, BCPS, the Army pharmacy consultant and program manager for the Army surgeon general. Another generally healthy geriatric patient took four different medications to help with sleep, but the clinical pharmacist realized that poor sleep hygiene — specifically a penchant for watching violent movies just before bed — kept the man awake.

The program has already enabled the Army to avoid costs associated with adverse drug effects, drug interactions, inappropriate therapy and incorrect durations and dosages. “It’s more efficient to have clinical pharmacists who are experts in optimizing medical therapy focus on that, rather than a nurse or doctor who is less familiar [with specific medications],” Maneval told U.S. Medicine.

As a result of the improvements in quality, safety and efficiency, Maneval says the program has an “ROI approaching 5:1; for every $1 invested, we should expect to see about $5 in savings, based on current models.”

The success — and future support — of programs such as Tripler’s depend on proving value as well as saving money. “We realized the need to have high-integrity information to document the value pharmacists provide, so we’ve developed a module that pharmacists use in real time as they counsel patients and provide interventions,” White told U.S. Medicine.

The models could use a little refinement, though, Maneval explained. “Cost avoidance can be thought of as a weak estimator. The VA uses the Archimedes model, which allows us to look forward into the future by using millions of people’s experience of healthcare to predict the outcomes and costs of changes in how we practice medicine,” he said. “If we reduce blood pressure by so much, for instance, how many hospitalizations, etc., will we forgo by doing that.”

Maneval suggested combining the Army’s current estimating module with Archimedes to get more accurate predictions of cost savings.

With the clinical pharmacy programs showing positive outcomes at Tripler and in a similar pilot conducted at Blanchford Army Community Hospital in Fort Campbell, KY, the Army surgeon general has allotted funds to support the growth of the program. Already 38 military treatment facilities have begun embedding clinical pharmacists into their medical home team and more will follow as funding is delivered, Spain said.

Programs such as this one at Tripler “make the case that clinical pharmacists add value beyond their traditional role,” the Army pharmacy consultant added. “Efforts at other MTFs and the Tripler pilot have persuaded senior decision-makers that expanding the role of clinical pharmacists is a worthwhile investment.”

That’s good news for pharmacists who hope to expand their scope of practice. “Pharmacists are seeking provider status,” said Spain. “We are seeking to determine the value proposition of clinical pharmacists in many activities across the DoD and even in the commercial sector. We have the patient’s perspective in mind — they don’t want adverse effects or to take ineffective drugs. They’re looking for the best quality of life. We hope to contribute to the tipping point where provider status is achieved.”