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4/26/2001

Physician Leaders Hear Details on Pharmacist Collaborative Drug Therapy Management

Cheryl A. Thompson

Leaders of the nation’s largest medical specialty society recently listened to one of their own and two pharmacists explain how the two groups of professionals can improve health care by collaborating to manage patients’ drug therapy. The one-hour session, held during a meeting of the board of governors for the American College of Physicians–American Society of Internal Medicine (ACP-ASIM) at its annual meeting in March, stemmed from the ongoing discussions the group’s representatives have had with leaders of several pharmacy organizations over the past year.

Collaboration between physicians and pharmacists "can dramatically improve health care if done in the right way," said Mary T. Herald, M.D., FACP, a few days after the session she organized and led. She chairs the ACP-ASIM Health and Public Policy Committee and co-chairs the physician–pharmacist group. "As health care is changing and therapy is becoming more complex, we need to think ‘outside the box,’" Herald said, adding that collaboration with pharmacists is better for patients and better for the people providing the care. In rural areas, she said, it "may be a lifesaver having the pharmacist take a role" in managing drug therapy.

The "right way" for collaborative therapy, Herald said, is for physicians to bear the final responsibility for patients’ medical care, not pharmacy practitioners who work independently. She said she and other physicians have grown annoyed with community pharmacists who adopt an aggressive role, refusing to fill a prescription without having a complete picture of the patient’s health status and medical care. Take the case of a pharmacist who refused to fill a patient’s new prescription for a beta-blocker because that person had previously received a beta-agonist inhaler. "My judgment is that he did not have asthma," said Herald, recounting one of her experiences as a private-practice internist and endocrinologist. "He had bronchospasm in an acute situation" and no longer used the inhaler, so there was no agonist–antagonist interaction to avert.

Many physicians are unaware of advances in pharmacists’ skills, knowledge, and abilities. "The mindset of most [physicians] is that the clinical pharmacist is still a person counting out pills," Herald said. To correct this misperception, she had two guest speakers describe contemporary pharmacy education and training and provide "a concrete example" of how collaborative practice can work.

C. Edwin Webb, Pharm.D., M.P.H., director of government and professional affairs at the American College of Clinical Pharmacy (ACCP), said he told attendees that pharmacists’ current educational and training paths do not differ as much from physicians’ as might be assumed. Two thirds of next year’s pharmacy school graduates will have earned a Pharm.D., and many of them had a bachelor’s degree before starting their pharmacy education, he told the audience. Residency training and specialization are becoming more common, as is board certification.

Session attendees next heard Leslie Dotson Jaggers, Pharm.D., BCPS, describe collaborative drug therapy management at the Fuqua Heart Center at Piedmont Hospital in Atlanta, where she reports to the center’s clinical director, a cardiologist. Early in her presentation, Jaggers said, she offered a supportive quote from a physician familiar to the attendees, a former member of the board of governors, who declared the need for cardiology centers to have their own cardiac pharmacist.

Anticoagulation Management Through Collaboration

As part of Piedmont Hospital’s anticoagulation management service, cardiovascular pharmacist Leslie Dotson Jaggers has a clientele of outpatients who have been referred to her by physicians.

She sees patients by appointment, at which time she determines their International Normalized Ratio (INR); updates information about their medical history, medications, herbal therapies, dietary supplements, and INRs; educates; and monitors for appropriate anticoagulation and complications. Jaggers ascertains how well patients have adhered to their medication regimen and assesses the status of the medical condition necessitating anticoagulation therapy. She then adjusts the dosage of warfarin, in accordance with a protocol, on the basis of the INR measurement she made and the patient interview. The referring physician receives a copy of Jaggers’ progress note, notification of a missed clinic appointment, and alerts about potentially serious drug interactions.

After one year, Jaggers told attendees at a special session preceding the annual meeting of the American College of Physicians–American Society of Internal Medicine, 69% of her 79 patients had an INR in the appropriate range, topping the accepted national benchmark. There were three events of major bleeding—an adverse event she would prefer occur less frequently but probably cannot eliminate. She said the patients were referred to her service by 19 cardiologists, neurologists, internists, hematologists, and oncologists.

Webb said the three speakers "hammered on the concept of collaboration."

"As soon as we wrapped up," Jaggers said, "they were coming up to the microphone." From this interaction, she had the impression that many but not all audience members were familiar with the type of service she provides. "It was a very healthy discussion."

Webb spotted some skeptics in the crowd. One physician, he said, described a community pharmacist who measured customers’ bone mineral density but did not refer those with low readings for a diagnostic workup by a physician to determine the source of the abnormal test value.

Herald said that most of the audience had worked with Pharm.D.-degreed pharmacists in hospitals. "We’re a little concerned about the B.S.-level pharmacists taking on the roles that we are more comfortable with the Pharm.D.s taking on," she said. "We have to illustrate how this can work in the community setting." This would be done, she said, by publicizing collaborations that work well, such as the one in Asheville, North Carolina, where appropriately trained community pharmacists provide diabetes management services.

Webb said he did not imply at any time that physicians should steer clear of collaborating with B.S.-degreed pharmacists. "It behooves the physician…to delve into the professional background of the pharmacists they want to collaborate with," he said, and not rely solely on the degree.

One aspect of Jaggers’ service that particularly appealed to Herald was the screening for potential drug interactions in a way that made the health care process more complete and balanced. "Polypharmacy is something that’s very common."

Herald said she told her follow internists: "I’m sure that the last patient we saw before coming to this conference was on at least five medications."

The meetings between ACP-ASIM and pharmacy organizations started in March 2000, Herald said, and occur quarterly. ASHP’s Henri R. Manasse, Jr., Ph.D., Sc.D., co-chairs the group. Completing the group are several physician members of ACP-ASIM; officials from the American Pharmaceutical Association, the American Society of Consultant Pharmacists, and the National Community Pharmacists Association; and ACCP’s Webb.

Selected Literature Citations on Pharmacist-Managed Anticoagulation Clinics

  • Lee Y-P, Schommer JC. Effect of a pharmacist-managed anticoagulation clinic on warfarin-related hospital readmissions. Am J Health-Syst Pharm. 1996; 53:1580-3.
  • Wilt VM, Gums JG, Ahmed OI et al. Outcome analysis of a pharmacist-managed anticoagulation service. Pharmacotherapy. 1995; 15:732-9.
  • Chiquette E, Amato MG, Bussey HI. Comparison of an anticoagulation clinic with usual medical care: anticoagulation control, patient outcomes, and health care costs. Arch Intern Med. 1998; 158:1641-7.
  • Conte RR, Kehoe WA, Nielson N et al. Nine-year experience with a pharmacist-managed anticoagulation clinic. Am J Hosp Pharm. 1986; 43:2460-4.
  • Garabedian-Ruffalo SM, Gray DR, Sax MJ et al. Retrospective evaluation of a pharmacist-managed warfarin anticoagulation clinic. Am J Hosp Pharm. 1985; 42:304-8.