Clinical pharmacist Managed Oncology Clinic In University Hospital

Graduation Project

CLINICAL PHARMACIST

MANAGED ONCOLOGY

CLINIC IN A UNIVERSITY

HOSPITAL DR. Sara Shaheen

Fathy Mohamed Al-Azhary

C l i n i c a l p h a r m a c i s t m a n a g e d o n c o l o g y c l i n i c

1-background

The purpose of the Symposium on Clinical Pharmacy is to describe the present and

future functional roles of clinical pharmacists in drug research, professional

education, and patient care. Clinical pharmacy is a relatively new professional

discipline, being only about 15 years old. This new breed of pharmacists is patient

rather than drug product oriented. The discipline arose out of dissatisfaction with

old practice norms and the pressing need for a health professional with a

comprehensive knowledge of the therapeutic use of drugs. The clinical pharmacy

movement began at the University of Michigan in the early 1960s, but much of the

pioneering work was done by David Burkholder, Paul Parker, and Charles Walton

at the University of Kentucky in the latter part of the 1960s. Clinical pharmacology

is a professional discipline that combines basic pharmacology and clinical

medicine. Its development began in the early 1950s, primarily as a result of the

efforts of Harry Gold. It has had a slower growth than clinical pharmacy but it has

made many important contributions to our knowledge of human pharmacology and

the rational use of drugs.

Beginning a new therapy for cancer can be frightening, especially when the patient

will be responsible for administering the medication at home. Often, these oral

cancer therapies have complicated schedules, strict administration guidelines, and

troublesome side effects. Helping patients understand how to safely take their oral

cancer medication and educating them on what to expect is extremely rewarding.

By checking in with patients periodically during treatment, we may be able to

identify a problem before it becomes severe and communicate this to the patient’s

oncology care team.

First we must know how clinical pharmacy began and it’s evolution through years

and what’s the meaning of clinical pharmacy , One of the most important

origination that form a great role in the evolution of the clinical pharmacy is ACCP

“American College of Clinical Pharmacology”

ACCP Founded in 1979 with 29 individuals to advance the evolving practice of

clinical pharmacy. ACCP now serves as the organizational home for nearly

10,000 clinical pharmacists.


The American College of Clinical Pharmacy (ACCP) is a professional and

scientific society that provides leadership, education, advocacy, and resources

enabling clinical pharmacists to achieve excellence in practice and research.

ACCP's membership is composed of practitioners, scientists, educators,

administrators, students, residents, fellows, and others committed to excellence in

clinical pharmacy and patient pharmacotherapy.

So we have to know the meaning of clinical pharmacy ,,

Clinical Pharmacy is a health science discipline in which pharmacists provide

patient care that optimizes medication therapy and promotes health, wellness, and

disease prevention. The practice of clinical pharmacy embraces the philosophy of

pharmaceutical care; it blends a caring orientation with specialized therapeutic

knowledge, experience, and judgment for the purpose of ensuring optimal patient

outcomes. As a discipline, clinical pharmacy also has an obligation to contribute to

the generation of new knowledge that advances health and quality of life.

Clinical pharmacists care for patients in a ll health care settings. They possess in-

depth knowledge of medications that is integrated with a foundational

understanding of the biomedical, pharmaceutical, sociobehavioral, and clinical

sciences. To achieve desired therapeutic goals, the clinical pharmacist applies

evidence-based therapeutic guidelines, evolving sciences, emerging technologies,

and relevant legal, ethical, social, cultural, economic and professional principles.

Accordingly, clinical pharmacists assume responsibility and accountability for

managing medication therapy in direct patient care settings, whether practicing

independently or in consultation/collaboration with other health care professionals.

Clinical pharmacist researchers generate, disseminate, and apply new knowledge

that contributes to improved health and quality of life.

Within the system of health care, clinical pharmacists are experts in the therapeutic

use of medications. They routinely provide medication therapy evaluations and

recommendations to patients and health care professionals. Clinical pharmacists

are a primary source of scientifically valid information and advice regarding the

safe, appropriate, and cost-effective use of medications


In a brief words

“Clinical Pharmacy is a health science discipline in which pharmacists provide

patient care that optimizes medication therapy and promotes health, wellness, and

disease prevention. The practice of clinical pharmacy embraces the philosophy of

pharmaceutical care; it blends a caring orientation with specialized therapeutic

blends a caring orientation with specialized therapeutic knowledge, experience,

and judgment for the purpose of ensuring optimal patient outcomes. As a

discipline, clinical pharmacy also has an obligation to contribute to the generation

of new knowledge that advances health and quality of life.”

As with any discipline, research is critical to the advancement of clinical

pharmacy. The need for pharmacist-researchers who possess both clinical

pharmacotherapy knowledge and biomedical research skills was recognized in the

Millis Commission Report in 1975.The Millis Commission defined "clinical

scientist" as an individual equally skilled and trained in a science and in pharmacy

practice. Their definition is consistent with the general definitions of clinician-

scientist used by the National Institutes of Health (NIH) and the Canadian

Institutes of Health Research.

The American Association of Colleges of Pharmacy (AACP) conducted a survey

that documented the severe shortage of pharmacy faculty in the United States. In

2002, of 67 schools responding to the survey (80% response rate), 417 faculty

positions were open, almost all of which were for positions in either pharmacy

practice (223 positions) or the pharmacy sciences (190 positions). With the steadily

increasing number of pharmacy schools and class sizes, the need for qualified

individuals to teach and advance the field of clinical pharmacy will continue to

expand. The need for pharmacist-researchers who possess both clinical

pharmacotherapy knowledge and biomedical research skills (of which clinical

pharmacy research is a subset) is critical as overall drug use increases and as

technology and science allow us to move toward better targeting of and more

individualized approaches to drug therapy.


2-Aim of the work

The aim of the clinical pharmacy is to ensure the patient's maximum well-being

and to play a meaningful role in the safe and rational use of drugs. The main goals

of clinical pharmacy are:

1. To assist the physician in doing a better job of prescribing and monitoring drug

therapy for the patient.

2. To assist medical and para-medical staff and documenting medication incidents

correctly.

3. To maximise the patient's compliance in drug use process.

Qualities of clinical pharmacist: 1. Communication Skill. The clinical pharmacist should have good

communication skills, in order to communicate with the patient and co-

professionals freely and effectively.

2. Clinical Skills. The clinical pharmacist should have thorough knowledge about

etiology of a disease, signs, symptoms. pathophysiology, laboratory tests,

pharmacokinetics. etc. He should be clinically trained for providing information on

rational drug use, related drug therapy, and for reviewing drug doses.

3. Professional Relationship. He should be able to understand and appreciate the

role of medical and para-medical staff wherever possible. He must accompany

physician on medical rounds to assist him by providing drug informations. The

physician, pharmacists and nurses should develop an inter-professional relationship

with each other to enhance the quality of patient care.

4. Empathy. Clinical pharmacist should possess a deep sense of shared

responsibility towards medical care of patients. It will help him in taking

medication history and gaining patient's confidence.

5. Monitoring Drug Therapy. Clinical pharmacist must help in monitoring drug

therapy because it is an on-going process and keeps on changing depending upon

patient's conditions.

Oncology pharmacists have a vital role in the health care team. Pharmacists

possess specialized knowledge about medications and how they work to fight

cancer. They work with the medical and nursing staff to maximize the benefits of

drug therapy while trying to minimize toxicities. Pharmacists also help coordinate

the complete medication plan, from inpatient chemotherapy infusions to what

medications need to be taken at home. Additionally, oncology pharmacists work

with the health care team to educate patients about what to expect during treatment

and ensure that each medication is given at the right time and dosed correctly.


Pharmacists perform daily evaluations of medication profiles to ensure each drug is

dosed appropriately. Pharmacists are also active in educating patients and family

members about what to expect during chemotherapy and following up with the

health care team to adjust medications if the patient is experiencing side effects

from chemotherapy.

No matter the setting, oncology pharmacists are true experts in the medications

used to treat cancer, as well as the medications used to manage complications of

cancer and side effects from its treatment. They can explain to patients exactly how

their medications should be taken. They can look at a patient’s current list of

medications to identify any worrisome drug interactions and then provide guidance

on managing these interactions. Oncology pharmacists also explain what side

effects may occur and assist in managing these side effects. Finally, oncology

pharmacists work closely with a patient’s oncologist in order to achieve the best

possible outcome.

And being able to manage a patient’s supportive care plan, which often focuses on

pain, neuropathy, nausea, or vomiting. Inorder to bring to this role in utilizing the

medication we must have the in-depth medication knowledge that an oncology

pharmacist has in order to best serve our patients.

Basic components of clinical pharmacy practice

1. Prescribing drugs

2. Administering drugs

3. Documenting professional services

4. Reviewing drug use

5. Communication

6. Counseling

7. Consulting

8. Preventing Medication Errors

Scope of clinical pharmacy

Drug Information

Drug Utilization

Drug Evaluation and Selection


Medication Therapy Management

Formal Education and Training Programs

Disease State Management

Application of Electronic Data Processing (EDP)

What activities can be undertaken to achieve the aim of clinical pharmacy?

The aim of clinical pharmacy is the best use of medicines.

Many activities can be undertaken to promote the best use of medicines.

Some clinical pharmacy activities include :

Documentation of patient pre-admission medication history

Documentation of patient allergies (including medication allergies)

Medication reconciliation (checking that medicines taken before

admission are continued in hospital if still necessary)

Clinical review of medications to ensure the patient is being treated as

best as possible

Participation in ward rounds

Discharge medication counselling

Patient referral

Therapeutic drug monitoring

Restriction and monitoring the use of antibiotics

Providing continuing education for other staff on the best use of

medicines

Drug use evaluation

Health promotion activities

Providing written information


3-Rationale for the project proposal

What do clinical pharmacists do?

Clinical pharmacists:

Assess the status of the patient’s health problems and determine whether the

prescribed medications are optimally meeting the patient’s needs and goals

of care.

Evaluate the appropriateness and effectiveness of the patient’s medications.

Recognize untreated health problems that could be improved or resolved

with appropriate medication therapy.

Follow the patient’s progress to determine the effects of the patient’s

medications on his or her health.

Consult with the patient’s doctors and other health care providers in

selecting the medication therapy that best meets the patient’s needs and

contributes effectively to the overall therapy goals.

Advise the patient on how to best take his or her medications.

Support the health care team’s efforts to educate the patient on other

important steps to improve or maintain health, such as exercise, diet, and

preventive steps like immunization.

Refer the patient to his or her doctor or other health professionals to address

specific health, wellness, or social services concerns as they arise.

Why should we consider clinical pharmacy?

Clinical pharmacy services are of considerable importance in all the hospitals

because clinical pharmacist can serve as a guide to physician for safe and rational

use of drugs. A clinical pharmacist can help to achieve economy in the hospital by

planning safe drug policies, suggesting means of reductions of waste, by

preventing misuse or pilferage of drugs and in the preparation of budget by

forecasting future drug needs of hospital, based upon their, drug utilization

patterns.

With a growing but already wide range of medicines and the increasing prevalence

of chronic diseases in all countries the best use of medicines is of growing

importance.


Some of the outcomes of clinical pharmacy and the best use of medicines are

Better patient health outcomes

Better patient medication understanding

Better patient medication usage

Decreased cost to the government and patient (decreased use of unnecessary

medicines, decreased risk of hospital admissions from medication issues)

Increased availability of medicines (medicines are used on only the people

who need them)

How do clinical pharmacists care for patients?

Clinical pharmacists:

Provide a consistent process of patient care that ensures the appropriateness,

effectiveness, and safety of the patient’s medication use.

Consult with the patient’s doctor(s) and other health care provider(s) to

develop and implement a medication plan that can meet the overall goals of

patient care established by the health care team.

Apply specialized knowledge of the scientific and clinical use of

medications, including medication action, dosing, adverse effects, and drug

interactions, in performing their patient care activities in collaboration with

other members of the health care team.

Call on their clinical experience to solve health problems through the

rational use of medications.

Rely on their professional relationships with patients to tailor their advice to

best meet individual patient needs and desires.

The Clinical Pharmacist

Stating explicitly that the clinical pharmacist cares for patients in all health care

settings emphasizes two points:

1) that clinical pharmacists provide care to their patients (i.e., they don’t just

“provide clinical services”), and

2) that this practice can occur in any practice setting. The clinical pharmacist’s

application of evidence and evolving sciences points out that clinical pharmacy is a

scientifically-rooted discipline; the application of legal, ethical, social, cultural, and

economic principles serves to remind us that clinical pharmacy practice also takes

into account societal factors that extend beyond science.


By stating that clinical pharmacists assume responsibility and accountability for

achieving therapeutic goals, the definition makes it clear that they are called upon

to be more than consultants. Further, the mention of managing therapy in direct

patient care settings is particularly important because it reinforces existing

definitions of the term “clinical.”

That is, clinical pharmacists are involved in direct interaction with, and observation

of, the patient. In addition, it is noted that clinical pharmacists practice both

independently and in consultation/collaboration with other health care

professionals, making it clear that they are members of an autonomous profession

within their scope of practice, yet also function as members of a cooperative health

care team. At the conclusion of this paragraph, attention is drawn to the scientific

impact of clinical pharmacist researchers by stating that they generate, disseminate,

and apply new knowledge that contributes to improved health and quality of life.

Roles Within the Health Care System. By noting that the clinical pharmacist is an

expert in the therapeutic use of medications, this section indicates that the clinical

pharmacist is recognized as providing a unique set of knowledge and skills to the

health care system and is therefore qualified to assume the role of “drug therapy

expert.” In addition, this expertise is used proactively

to ensure and advance rational drug therapy, thereby averting many of the

medication misadventures that ensue following inappropriate therapeutic decisions

made at the point of prescribing. Stating that the clinical pharmacist is a primary

source of scientifically valid information and advice on the best use of medications

emphasizes that the clinical pharmacist serves as an objective, evidence-based

source of therapeutic information and recommendations. This expertise extends

beyond traditional medications to include nontraditional therapies as well. Finally,

indicating that clinical pharmacists routinely provide therapeutic evaluations and

recommendations underscores the fact that their daily practice involves regular

consultation with patients and health care professionals regarding medication

therapy evaluations and recommendations.


4-Introduction Clinical oncology is a major participant in any multi-disciplinary team, which

would meet regularly to discuss site specific cases of tumors. Other members

would be site specific surgeon, palliative care physician, radiologist, pathologist,

specialist nursing staff and appropriate hematologist and medical oncologist.

It consists of three primary disciplines: medical oncology (the treatment of cancer

with medicine, including chemotherapy), surgical oncology (the surgical aspects of

cancer including biopsy, staging, and surgical resection of tumors), and radiation

oncology (the treatment of cancer with therapeutic radiation).

Oncology is concerned with:

The diagnosis of any cancer in a person (pathology)

Therapy (e.g. surgery, chemotherapy, radiotherapy and other modalities)

Follow-up of cancer patients after successful treatment

Palliative care of patients with terminal malignancies

Ethical questions surrounding cancer care

Screening efforts:

o of populations, or

o of the relatives of patients (in types of cancer that are thought to have

a hereditary basis, such as breast cancer)

There needs to be a common shared understanding of the roles of the doctor in the

contemporary healthcare team. ...Such issues need to be urgently considered by

key stakeholders and public consensus reached before the end of 2008 .

To date, the information published regarding workforce implications has focused

on physicians, nurse practitioners, and physician assistants. But oncology clinical

pharmacists also can assist with direct patient care and patient education activities.

Much effort and research have been presented over the past 3 years about the

future of the practice of oncology. It is estimated that a significant shortage of

qualified oncology and hematology health care professionals will be seen by 2020.

To date, the information published regarding workforce implications has focused

on physicians, nurse practitioners, and physician assistants. However, another

clinical resource has been overlooked in available research and publications. There


are a growing number of oncology clinical pharmacists who can assist with direct

patient care and patient education activities. In fact, in certain states, clinical

pharmacists are providing direct patient care. Nationally speaking, although it is

not uncommon for a clinical pharmacist to practice at this level, there is a paucity

of literature documenting this practice. This article serves to introduce these

concepts and logistics.


5-review of literature

This was a retrospective descriptive analysis of clinical interventions by the

clinical oncology pharmacist from

September 4, 2004 to October 27, 2006. Interventions were categorized as either

drug-related or consultative. Drug-

related interventions included medication reconciliation, dosing, and adverse effect

management and prevention.

Consultations incorporated drug information questions, patient visits, and patient

education sessions. Information was extracted from an online documentation

program linked to medical charts.

Results.

A total of 583 clinical interventions were documented among 199 patients.

Average time spent per intervention

was 10 minutes. Drug-related and consultative interventions accounted for 35%

and 65%, respectively. Included among

the drug-related interventions were adverse events (131), medication reconciliation

(52) and dosing (22). Consultation

services consisted of patient education (143), patient visits (124) and drug

information (25). The on-site pharmacist saved

$210,000 by admixing chemotherapy. Patient and colleague surveys evaluated

pharmacist services with positive ratings of

95% and 98%, respectively.

Conclusion.

Analysis of clinical interventions, cost-savings, and feedback from patients and

colleagues confirmed

beneficial services provided by a clinical pharmacist in this outpatient oncology

center.

OBJECTIVES: To assess the effect of clinical pharmacist interventions on the

clinical outcomes in oncology patients.

METHODS: A total of 100 patients received their chemotherapy cycles with

clinical pharmacy interventions were enrolled in the present study during January

2007 to January 2008. Clinical pharmacy interventions

include: Detecting medication errors by using a modified form of the American

Society of Hospital Pharmacists (ASHP) worksheet. Correcting those errors and

sending recommendations to the medical staff.


RESULTS: The clinical pharmacy interventions reduced the number of

medication errors from 1548 to 444 which was statistically significant (p_0.004). A

total of 1104 clinical pharmacy interventions were documented in this present

study. Forty-five percent of clinical pharmacy interventions have led to increase in

the efficacy of chemotherapy regimen and 54.7% have led to decrease in the

chemotherapy toxicity. Seventy six percent of the errors recorded in the present

study occurred in the prescribing stage, about 20%in the administration stage and

3.8% in the dispensing stage.

CONCLUSIONS: The clinical pharmacy interventions among oncology patients

can reduce the number of medication errors; improve the clinical outcomes through

increasing chemotherapy efficacy and reducing the toxicity.


6-methodology

The World Health Organisation defines the rational use of medicines as a

situation where ‘patients receive medicines appropriate to their clinical needs, in

doses that meet their own individual requirements, for an adequate period of time,

and at a price the patient can afford’.

The best use of medicines can be expanded from this definition.

The best use of medicines is occurs when

The most effective medication option is used based on strong evidence

There is an indication for use

There are no contraindications for use

The dose is correct

The Route is correct

The frequencyis correct

The Duration of treatment is correct

The Formulation is correct

It is appropriate for patients age

It is appropriate for patients weight or Body Surface Area (BSA),

depending on which is more applicable

It is appropriate for the patients renal function

It is appropriate for the patients hepatic function

It is appropriate considering other clinical investigations for the patient

It is important to ensure that

Appropriate monitoring can be completed

Medicine is taken at the appropriate time in reference to meals

There are no drug interactions

(if not possible, the drug interactions should be managed

appropriately with appropriate monitoring where appropriate)

Medicine use is cost Effective The best use of medicines requires

understanding from the doctor, pharmacist, other health workers and the

patient.

The best use of medicines is not always practiced. For example

Doctors can sometimes feel pressured to give medicines to patients even

if it is not needed

A patient may take medicines without speaking with a health worker

A doctor may prescribe a medication but the patient may not use it


Pharmacists may not ensure that the patient can take the medicine

properly

Where can clinical pharmacy happen?

As mentioned in above sections, the best use of medicines (the aim of clinical

pharmacy) is the responsibility of many health care workers. This should be an aim

of practice in all health care facilities, whether are pharmacist is there or not.

Clinical pharmacy activities can be practiced in a range of areas, including

Hospital wards

Hospital clinics

Inpatient pharmacy department

Outpatient pharmacy department

Community pharmacy

Pharmacists may assume that clinical pharmacy only occurs on wards

interacting directly with patients and other health care workers. However,

all pharmacists should be clinical pharmacists, at least to some extent.

There are many advantages of completing clinical pharmacy activities on

a hospital ward, including

Access to patient information

Access to other health care workers

Access to patients

Access to processes involving medicines use

Participation in ward rounds

Participation in discussions on patient management

Although the ward provides many advantages to conduct clinical pharmacy

activities it is not always possible to do this.

If it is not possible to conduct clinical pharmacy activities on hospital wards,

other areas can be used to promote the best use of medicines.

The disadvantage is that the pharmacist is unlikely to have easy access to the

resources, information and staff that a ward based clinical pharmacist would.


7-Budget

One time costs:

IRB Review Fee $1744 + 29% = $2250.

IRB Continuing Review Fee $ 581 + 29% = $750.

IRB Amendment Review $ 388 + 29% = $500

IRB Preparation Fee $ 1500 (suggested fee)

Administrative Fee $ 3000 ( suggested fee)

Investigational Drug Pharmacy set-up fee

Archive document storage fee $100 / year * 7 years

Source document binders $8.00 per patient * X patients

Advertising for Recruitment Fee

Total

Indirect Cost 29%

Total One time costs

Principal Investigator:

Division:

Protocol Title:

Protocol Number:

Sponsor:

IRB Approval Number:

Start date:

Study duration:

List all procedures and all visits

Total

per

Procedure Baseline Visit 1 Visit 2 Visit 3 Final Visit patient Sponsor Other

History and Physical 200$ 50$ 50$ 50$ 50$ X

Lab tests 300$ 300$ 250$ 50$ 300$ X X

MRI scan 1,500$ 1,500$ X

Study Drug administration 35$ 35$ 35$ X

Sub total 2,000$ 385$ 335$ 135$ 1,850$

Indirect rate 29% 580$ 112$ 97$ 39$ 537$

Total per visit 2,580$ 497$ 432$ 174$ 2,387$ 6,069$

* Consider 10% inflation per year for multi-year trials

Start-Up Costs: (One Time Fees) Start-Up Costs

IRB Initial Review Fee 1,744.00

IRB Amendment Review 581.00

IRB Continuing Review 388.00

IRB Preparation Fee 1,500.00

Subject Recruitment 5,000.00

Investigational Drug Pharmacy set-up Fee 1,000.00

Data Archival fee (100/yr for 7 years 700.00

Direct Costs 10,913.00

Indirect Costs (29 % of Direct Costs) 3,164.77

Sub Total Start-Up Costs: $14,077.77

Payer

Insurance -

Standard of

Care


The budget must total the estimated patient costs plus all one-time allowable

fees.

All industry sponsored expenses are subject to F&A (Facilities and

Administrative Costs) or Indirect Costs – (Overhead)

Industry sponsored clinical trials must use the Indirect rate of 29%. Federally

sponsored clinical trials indirect rate is 54%. You do not pay indirects on

patient care costs in Federal trial budgets.

IRB Review Fees

Initial review - $2250 ( $1744 + $506 indirect rate)

Continuing review - $ 750 ( $ 581 + $169 indirect rate)

Amendment review - $ 500 ( $ 288 + $112 indirect rate)

Points to Remember

University Expenses (Direct Costs and F&A Costs) Must Be Reflected In

The Budget.

o Personnel (salary and fringe benefits)

o Office and Clinical Supplies

o Pharmacy Fees

o Laboratory Fees

o Patient Reimbursement Fee (e.g., travel, parking)

o Publication Costs

o Institutional Review Board – IRB Review Fees

o Determine if there will be professional charges required for the

technical tests performed. An example would be an ECG with

interpretation by a Cardiologist.

o Either edit the sponsor’s budget or create an Excel spreadsheet to

reflect all costs of the trial.


Health Expenditures has been increasing as a percentage of the nation’s Gross

Domestic Product (GDP) (Accounts for 15-20 %).

»In USA, Sales of nonprescription drugs have increased from $700 millions in

the 1950s to well into the billions of dollars ($287 billion in 2007).

»Thus, for half a century clinical pharmacy has been succeeding to set its feet

strongly and thoroughly through its activities in the healthcare services.

Whereas substantial numbers of studies have reported improved patient care and,

in some cases, reduced costs at individual clinical sites, none have evaluated the

impact of clinical pharmacy services and pharmacy staffing on the total cost of

care in our health care system.

Of 104 studies published between 1988 and 1995, 89% described positive

financial benefits of these services, with a mean cost: benefit ratio of 16.70:1

(every dollar invested in clinical pharmacy services resulted in a cost

reduction of $16.70).

Improved drug therapy should have a profound impact on the total cost of care

by decreasing:

1.Lengths of hospital stays.

2.Adverse drug reactions.

3.Infection rates.

4.Law suits.

5.Number of personnel to care for patients.

and so on.

»Thus, clinical pharmacy services may increase the efficiency of health care and

reduce costs.

There are a lot of clinical pharmacy services that work on that, including but not

exclusive to:

1.Centrally delivered services:

1.Medical treatment evaluation.

2.Drug and poison information.

2.Patient-specific services:

1.Adverse drug reaction (ADR) monitoring.


2.Drug therapy monitoring.

3.Drug counseling.

4.Medical rounds participation.

It is estimated that in this process each dollar of pharmacist salary cost was

associated with $31.92 reduction in total cost of care.

An unbiased source of drug information may promote better patient care and thus

reduce total cost of care.

»This service may contribute to lower total cost of care, as up to 28% of all

hospital admissions which were attributed to drug-related morbidity and mortality.

Having trained personnel to provide information could reduce these costs. In

addition, ADRs in hospitals are often preventable if detected early, and could be

reduced with better information systems.

»The presence of this service may also indicate medical staff open to input from

pharmacists and likely to accept recommendations on drug therapy, which may

result in lower costs.

Since the drug information service is often the process for formulary management

coordination in the hospital, it is important in controlling drug costs that are a

component of the total cost of care.

In the process, Each dollar of pharmacist salary cost was associated with $602.16

reduction in total cost of care. It also resulted averagely in 10.3 fewer

deaths/hospital/year.

»Thus, Pharmacist-provided drug information should be considered one of the

foundation clinical pharmacy services for hospitals.

Adverse drug reactions are the most common untoward events occurring in

hospitals and significantly increase the cost of care.


»The presence of this service indicates a hospital that has an active program to

detect and prevent ADRs, and thus may reduce the cost of care associated with

these problems.

This service has a profound effect on health care cost savings, as it limits:

1.Hospital Readmissions.

2.Extensive drug use.

3.Hospital stay period.

»In the process, each dollar of pharmacist salary cost was associated with

$2988.57 reduction in total cost of care.

Since medical rounds is where key decisions are made regarding patient care,

pharmacists' participation may prospectively ensure optimum drug therapy, thus

improving patient care and reducing health care costs.

»It may also indicate a hospital wide system that allows many health care

professionals to have direct input into decision making, thus improving health care

and reducing costs.

Although this was one of the more expensive clinical pharmacy services (total

salary), it was associated with the greatest reduction in total cost of care/hospital.

(Around $ 8,000,000/hospital/year)

»In the process, each dollar of pharmacist salary cost was associated with

$252.11 reduction in total cost of care.


8-Challenges

Despite a societal need for clinical pharmacy scientists, some barriers exist.

Challenges that pertain to all clinical investigators, including pharmacist-

researchers, are enhancing public participation in clinical research, guaranteeing an

adequately trained workforce, and obtaining funding. The difficulties facing

clinical pharmacy researchers are similar to and in some cases amplified compared

with those faced by some other clinical researchers. In addition, the increasing

competition for suitable patients, conflicts of interest and their impact on public

opinion of clinical research, increasing regulation, and privacy concerns all affect

the ability of pharmacists to recruit necessary participants for clinical research.

The ACCP's strategic plan lays out a direction for advancing their research

mission. The ACCP envisions that within the next 10-30 years, a significant

increase will occur in the number of clinical pharmacy scientists who will serve as

principal investigators for pharmacotherapy research, generate a substantial portion

of the research that guides drug therapy, and compete successfully with other

health care professionals for research funding. It is also envisioned that ACCP

members will commonly serve as principal investigators for pivotal clinical trials

and other pharmacotherapy research, and will compete successfully for research

funding that creates new knowledge and guides drug therapy. The ACCP has set

goals to increase the impact of pharmacist-initiated research, to encourage the

pursuit of research careers by clinical pharmacists, and to foster individual

members in their research and scholarly capabilities.

Challenges to be considered

There are many factors to consider when setting up a clinical pharmacy

service, and these may include

Potential staff

Ability to train staff

Potential time to be allocated to a clinical pharmacy service

Where the clinical pharmacy service will be based


What clinical pharmacy activities will be completed In practice, a pharmacist

may identify less busy times in the pharmacy where they can prioritise clinical

pharmacy activities according to health centres needs and the pharmacy’s ability to

address those needs. Examples may include

Pharmacist A in Pacific Island Country A identifies counseling to outpatients as a

problem.

The pharmacist chooses to complete training to improve counselling practice or

create medication leaflets to assist this process.

Pharmacist B in Pacific Island Country B identifies medication understanding of

inpatients as a problem. The pharmacist chooses to create discharge medication

lists and complete comprehensive discharge medication counselling for patients

going home

Pharmacist C in Pacific Island Country C is approached by a doctor from the

diabetes clinic who believes patient understanding important for disease

management. After discussion, the pharmacist agrees to provide medication

counselling to priority patients at this clinic Implementing a clinical pharmacy

service

When it comes to implementing a clinical pharmacy service consideration should

be given to the following

Approval to implement a clinical pharmacy service (department approval,

hospital approval etc.)

Promoting your service to other health care professionals

Compiling the required clinical resources for the clinical pharmacy service

Compiling standard operating procedures to facilitate a consistent service

One of the major challenge we face that who can do clinical pharmacy ?

Clinical pharmacy is normally provided by a pharmacist.

In many countries pharmacists are not available so other health care workers may

complete the activities of a clinical pharmacist.

The specific skills of a clinical pharmacist should include, but not necessarily

limited to

Knowledge of medicines (doses, frequency, mechanism of action, indications for

treatment, contraindications for treatment, adverse effects, interactions, available

formulations, how to monitor treatment etc.)


Knowledge of clinical presentation, diagnosis, pathophysiology and management

of common disease states

Ability to identify issues with medicines use and suggest management strategies

Knowledge of drug information resources (what resources to use, how

to use these resources)

Knowledge of culture of the community and common perceptions about

medicines in the community

Ability to communicate appropriately and effectively with patients and other

health care workers in a professional manner

Knowledge of commonly used herbal or alternative medicine in the area

However, clinical pharmacy activities can be provided by other health care

workers to ensure the best use of medicines.

The best use of medicines is the responsibility of all health care workers.

Prescribers (doctors, dentists and some nurses) have the greatest responsibility to

ensure the best use of medicines as they prescribe medicines.

It is obvious that prescribers have a great responsibility to practice

the best use of medicines.

However, other health care professionals can also contribute to the best use of

medicines, for example

Nurses can contribute to the best use of medicines

.

Often nurses are the prescribers of medicines.

They spend the most time with patients and have significant knowledge

of medicines and disease processes.

Nurses can also contribute by observing patients and assisting with identification

of medication effects and adverse drug reactions

A dietician may notice that a patient has suffered from gastric upset since starting

a medicine (e.g. NSAID or corticosteroid) which has resulted in decreased app

etite; the patient’s condition is worsening as a result. If the dietician speaks with

the prescriber the

therapy can be improved. This increases the chance of better health outcomes for

the patient

Physiotherapists often need to recommend the use of anti - inflammatory

medicines or other medicines for pain management. They need to make patients

aware of the side effects of those medicines. They also need to be aware of

patients’ other conditions and medicines being used and will consult the doctor if

needed and advice the patient appropriately.


A physiotherapist may also notice that a patient has become quite dizzy (e.g. due to

some blood pressure medications), making it difficult to do some exercises in

hospital and maybe

when the patient goes home. If the physiotherapist speaks with the prescriber

the therapy can be improved. This could significantly improve the health outcomes

of the patient

A pharmacist or pharmacy department may be able to provide training in the use of

medicines to these health care workers so they have the ability to contribute to the

best use of medicines.

Monitoring the impact of a clinical pharmacy service

Reason for monitoring the impact of a clinical pharmacy service include

Maximizing benefit to your patients

To justify ongoing support for a clinical pharmacy service

A range of indicators can be monitored to measure the impact of a clinical

pharmacy service, and these may include

Clinical interventions

Number of patients who have received medication counselling

from a clinical pharmacist

Number of ward rounds attended by the clinical pharmacist

Number of patients who had a clinical review completed by a clinical

pharmacist

Number of referrals received by the clinical pharmacist to complete a

clinical review

Although it is important to measure the impact of a clinical pharmacy service, it

should be noted that monitoring the service should never

compromise the clinical pharmacy service. Therefore,

monitoring should be completed by selecting a few indicators which are simple to

gather data on.

In particular, it is a very large task to monitor clinical interventions.


9-Conculsion

oncology clinics provide an excellent opportunity to involve pharmacists. A clinical

pharmacist has a significant role in outpatient clinics and can potentially lead to

an overall decrease in health care costs and to an improvement of the quality of

patient care.

10-Summary

The clinical pharmacy movement began at the University of Michigan in the early

1960

ACCP Founded in 1979 and had a great role in it’s evolution

importance in all the hospitals because clinical pharmacist can serve as a guide to

physician for safe and rational use of drugs. And decrease medication errors and

drug use evaluation .

we face many challenge as fund and the educational process that helps in to

increase the knowledge of different fields of the pharmaceutical science.

And we can get from this that :

Clinical Pharmacy has become a trend at the developed countries in the light of the

hard pressing economical crises and political conflicts. By its activities and

services, it contributes a lot to alleviating the burden on the annual medical budget.

»Its cost savings luster persuaded the governments to invest a lot in it and give

greater roles to the clinical pharmacists, thus improving the general healthcare

service.


11-Refernces

http://sci-hub.org/doi/10.1200/JOP.000037

http://www.accp.com/docs/about/ClinicalPharmacyDefined.pdf

http://www.accp.com/about/clinicalPharmacyDefined.aspx

http://www.ucdenver.edu/academics/colleges/pharmacy/currentstudents/OnCampusPharmDStudents/

StudentOrganizationsNew/OutsideOrganizations/Documents/ACCP_Information_slides.pdf

http://en.wikipedia.org/wiki/Clinical_pharmacy

http://www.medscape.com/viewarticle/540716_4

http://en.wikipedia.org/wiki/Oncology

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2936477/

http://jop.ascopubs.org/content/4/4/172.full

http://sci-hub.org/doi/10.1177/107815529900500104

http://opp.sagepub.com.sci-hub.org/content/early/2011/01/14/1078155210389216.short


https://www.rcr.ac.uk/docs/general/pdf/THEROLEOFDOCTORJune2008.pdf

http://www.medscape.com/viewarticle/755894

http://ashpadvantage.com/leaders2011/docs/_Workshop%204_Clinical%20Dashboards%20Proceedings.

pdf

http://www.pppmag.com/article/1204/September_2012/Financial_Analysis_of_Drug_Management_an

d_Pharmacy_Costs/

http://www.slideshare.net/srkhere/clinical-pharmacy-16402443

http://www.bopawebsite.org/contentimages/wysiwyg/Michael_Dooley_and_Robert_Duncombe.pdf

http://www.ncbi.nlm.nih.gov/pubmed/7016931

http://courses.polhncourses.org/mod/resource/view.php?id=31253





http://sci-hub.org/doi/10.1200/JOP.000037

http://www.facebook.com/l.php?u=http%3A%2F%2Fwww.accp.com%2Fdocs%2Fabout%2FClinicalPharmacyDefined.pdf&h=oAQGVKqsG

http://www.facebook.com/l.php?u=http%3A%2F%2Fwww.accp.com%2Fabout%2FclinicalPharmacyDefined.aspx&h=oAQGVKqsG

http://www.ucdenver.edu/academics/colleges/pharmacy/currentstudents/OnCampusPharmDStudents/StudentOrganizationsNew/OutsideOrganizations/Documents/ACCP_Information_slides.pdf

http://www.ucdenver.edu/academics/colleges/pharmacy/currentstudents/OnCampusPharmDStudents/StudentOrganizationsNew/OutsideOrganizations/Documents/ACCP_Information_slides.pdf

http://www.facebook.com/l.php?u=http%3A%2F%2Fen.wikipedia.org%2Fwiki%2FClinical_pharmacy&h=oAQGVKqsG

http://www.medscape.com/viewarticle/540716_4

http://en.wikipedia.org/wiki/Oncology

http://www.facebook.com/l.php?u=http%3A%2F%2Fwww.ncbi.nlm.nih.gov%2Fpmc%2Farticles%2FPMC2936477%2F&h=oAQGVKqsG

http://jop.ascopubs.org/content/4/4/172.full

http://sci-hub.org/doi/10.1177/107815529900500104

http://opp.sagepub.com.sci-hub.org/content/early/2011/01/14/1078155210389216.short


https://www.rcr.ac.uk/docs/general/pdf/THEROLEOFDOCTORJune2008.pdf

http://www.medscape.com/viewarticle/755894

http://ashpadvantage.com/leaders2011/docs/_Workshop%204_Clinical%20Dashboards%20Proceedings.pdf

http://ashpadvantage.com/leaders2011/docs/_Workshop%204_Clinical%20Dashboards%20Proceedings.pdf

http://www.pppmag.com/article/1204/September_2012/Financial_Analysis_of_Drug_Management_and_Pharmacy_Costs/

http://www.pppmag.com/article/1204/September_2012/Financial_Analysis_of_Drug_Management_and_Pharmacy_Costs/

http://www.slideshare.net/srkhere/clinical-pharmacy-16402443

http://www.bopawebsite.org/contentimages/wysiwyg/Michael_Dooley_and_Robert_Duncombe.pdf

http://www.ncbi.nlm.nih.gov/pubmed/7016931






Clinical pharmacist Managed Oncology Clinic In University Hospital

Health & Medicine

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