Expanding the role of clinical pharmacists in community ... · PDF file24 oe VOL. 13, NO. 4,...

24 oe VOL. 13, NO. 4, NOVember 2014

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Expanding the role of clinical pharmacists in community oncology practiceresults of implementation at the Jack ady Cancer ClinicRoxanne Dobish1, BSc Pharm; Carole Chambers1, BSc Pharm, MBA; Kevin Iwaasa2, RN; Brenda Hubley, BSc, RTT, ACT1; Malcolm Brigden2, MD1. CancerControl Alberta, Alberta Health Services; 2. Jack Ady Cancer Centre in Lethbridge

AbstrAct

Increasing demand for cancer care services in the com-munity setting is putting pressure on ambulatory cancer clinics to become more productive and efficient. Limited

numbers of medical oncologists means that other health-care professionals must work to their full scope of prac-tice to enable oncologists to focus on activities only they can undertake. Oncology pharmacists have the potential to assume a greater role in patient care as part of multi-disciplinary teams in the community setting. This study evaluates a pilot project undertaken at the Jack Ady Cancer Clinic (JACC) in Alberta to implement an expanded pharmacist role that included direct interaction with patients and greater integration into the care team. The primary objective was to improve use and results of antiemetics for patients undergoing cancer chemotherapy. One-year results of the nonrandomized study found that

the new pharmacist role had a positive impact on the incidence and severity of chemotherapy-induced nausea and vomiting (CINV). The acceptability and sustainabili-ty of the increased pharmacist role were further assessed through workload analysis, as well as team member and patient surveys, and showed overwhelmingly positive reception of the new role by clinicians and patients. Results strongly support the benefits of an expanded role for clinical pharmacy services. Further research is needed on the impact of the expanded clinical pharmacist role on specific patient outcomes, continuity of care and cost-effectiveness.1,2,3

Key words: Oncology pharmacy services, pharmacy department, clinical pharmacy services, clinical pharmacist, expanded role clinical pharmacist, patient centered care, quality of care, individualized patient care

IntroductIonThe aging demographic of Western societies is accompanied by higher cancer incidence, placing increasing strain on medical oncology resources.4,5 In Canada, there is already a significant shortage of qualified medical oncology staff, especially in the setting of community oncology practice. Optimum resource utilization mandates that whenever pos-sible, medical oncologists should focus on activities only they can do.4 In the area of medication, these include the implementation and prescription of new chemotherapy plans in the adjuvant and metastatic setting, as well as changes in therapeutic planning as disease recurs or progresses. In many centres, oncology physicians are also the only health-care professionals allowed to enter the actual chemotherapy orders, a process that has become computerized, and increasingly complex and time-consuming. To meet these greater demands, there is increasing emphasis for all oncol-ogy professionals to practice to their full scope of practice.4,5

In some Canadian provinces, pharmacists are now empow-ered to administer injections and prescribe medications in certain well-defined clinical scenarios.3,5,6 The prescription of antiemetics, as well as other support medications used in cancer chemotherapy, has been reasonably standardized and is often algorithm-based, making it a suitable area in which to expand the role of clinical pharmacists.5-8 In theory, this would free up medical oncology staff to concentrate on other activities.7,8

A pIlot project to expAnd the oncology phArmAcIst roleClinical pharmacists are well established throughout the Alberta Health Services (AHS) network of acute and ambu-latory care services, including CancerControl Alberta’s ter-tiary cancer centres. In regional cancer centres such as the Jack Ady Cancer Clinic (JACC), pharmacists typically pro-vide chemotherapy medication services, operating from the pharmacy dispensary with a focus on safe drug distribution and some patient teaching. Oncology pharmacists spend much of their time in the dispensary, without a significant degree of face-to-face patient interaction.5

The JACC, a medium-sized comprehensive regional cancer centre that provides diagnosis and treatment services to cancer patients under the AHS CancerControl portfolio, was selected as the site for a pilot project to expand the role

roxanne dobish, bsc pharm, is Pharmacy manager, at CancerControl Alberta, Alberta Health Services; email: [email protected]: The authors acknowledge the contributions of the three pharmacists who participated in the study: Nancy Howard, Janna Federkell and Susan Schindeler.

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of the oncology pharmacist in the community oncology setting. The project was meant to support the priority artic-ulated in March 2013 by AHS Pharmacy Services to build workforce capacity and facilitate staff working to full scope of practice. Funding was provided over 18 months to sup-port the expansion of the clinical role of 3 existing JACC pharmacists, who together make up 1 full-time equivalent. Preliminary efforts focused on pharmacy services around antiemetic therapy for patients undergoing chemotherapy. The goal was to seamlessly integrate the clinical pharmacist into the clinic work processes and provide real-time phar-macy support for the multidisciplinary care team. Figure 1 provides a comparison of old and new paradigms.

The clinical pharmacists were relocated from the dispen-sary to the workstation alongside other members of the multidisciplinary team. As part of each new patient consult, and before the patient saw the medical oncologist, the clin-ical pharmacist would conduct a preliminary face-to-face assessment involving medication reconciliation, drug-relat-ed problems, documentation of past and present medica-tion history, allergies and adverse drug events, as well as a review of pertinent laboratory findings.

Immediately after the initial physician consultation, the pharmacist would again directly interact with the patient to review the proposed chemotherapeutic plan and propose an antiemetic regimen. The pharmacists employed updated American Society for Clinical Oncology (ASCO) guidelines in determining appropriate antiemetic regimens.9 This pro-

cess enabled the clinical pharmacist to review the chemo-therapy orders as entered by the physician and verify that dosing and accompanying supportive care measures were appropriate. During individual patient counselling, the pharmacist provided the patient with verbal and written information, including a medication calendar, and the phar-macy telephone number to call during clinic hours if they experienced drug-related problems.

Following the initial chemotherapy administration, the clinical pharmacist initiated a followup telephone call to assess chemotherapy-induced nausea and vomiting (CINV) status and, if needed, schedule an additional face-to-face consultation before or during the next chemotherapy session. For subsequent cycles of chemotherapy, followup calls were provided on an as needed basis. Pharmacy interventions following the initial patient visit also included detection of adverse events or medication errors and monitoring for patient noncompliance. Complex or unresolved issues iden-tified by patients were discussed with the medical team if required (e.g. adjustments to antiemetic medications).

The increased face-to-face interaction with patients represented an entirely new paradigm for pharmacy operations, as outlined in Figure 1. While the pilot project focused primarily on CINV, the inevitable effect of improved access to the pharmacist led other team members to request addi-tional services such as pharmacist-written prescriptions or information and followup on other chemotherapy or related medications.

FIGURE 1. The updated jacc clinical pharmacist model for medical oncology consults

OLD PARADIGM

New patient consult with nurse/physician Pharmacy component: physician and nurse provided brief description

of chemotherapy regime, side effects and antiemetics

Patient education session

Pharmacy component: dispensary pharmacist would spend 15 to 20 minutes reviewing individual chemo drugs and side effects

chemotherapy appointment

Pharmacy component: nursing usually re-reviewed chemotherapy process and antiemetics just prior to chemotherapy treatment

Other pharmacy interactions

Minimal other direct patient interaction, pharmacist might have brief discussion with individual patient regarding some aspect of chemotherapy, but pharmacists

activities generally confined to the dispensary

NEW PARADIGM

Initial clinical pharmacist consultPharmacy component: detailed pharmacist history including drug interactions,

medication reconciliation, allergies, etc.

Second clinical pharmacist consult

Pharmacy component: postphysician visit, a general discussion of chemotherapy, detailed discussion of antiemetic drugs, provision of additional dispensary contact

information; frequent provision of a written antiemetic plan; following APA certification, antiemetic and other scripts provided directly by clinical pharmacist

Patient education session

Pharmacy component: dispensary pharmacist still spends 15 to 20 minutes reviewing individual chemo drugs and side effects

chemotherapy appointment

Pharmacy component: clinical pharmacist available for discussion at the time of chemotherapy if any additional questions regarding side effects or antiemetic control;

possible provision/update of written antiemetic plan

Postchemotherapy followup

Pharmacy component: at least 2 followup telephone consultations from the clinical pharmacist, 1 and 3–4 days later; after 1st chemotherapy cycle, subsequent telephone

calls as required


resultsClinical workload AHS Pharmacy Services has collected clinical workload hours related to direct patient care as a key performance indicator since the summer of 2010. All pharmacists have been required to collect and submit such data on 8 standardized clinical workload measures. Pharmacy Services concluded that the average clinical pharmacist should be expected to report 75% of their workload as clinical hours; for a 1.0 full-time equivalent (FTE) clinical pharmacist position, this would translate to approximately 116 hours/month. In examining the JACC project workload statistics for June 2013 through May 2014, the actual average required was 0.9 FTE/month. Based on these results, it was anticipated that following achievement of full prescribing status, one FTE clinical pharmacist would be required to maintain clinical pharmacy service levels at JACC.

Medication reconciliation Medication reconciliation is currently a required organiza-tional practice by Accreditation Canada and constitutes a high priority for AHS. This also represents a key expected activity for clinical pharmacists. Medication reconciliation statistics (including the number of discrepancies identified) from the pilot project (August 2013 to July 2014) are provided in Table 1.

Nausea and vomiting controlThe clinical pharmacists profiled individual patients for followup phone calls in order to assess both acute and delayed CINV control after the first cycle of chemotherapy. Over a 1-month period (November to December 2013),

project evAluAtIonThe project was evaluated for its ability to meet the follow-ing objectives: • Implementation of an initial pharmacist consultation/

assessment for each new medical oncology patient in conjunction with the initial medical oncologist visit (includes medication reconciliation and a review of any clinical parameters that might impact on subsequent chemotherapy)

• Recommendation and implementation of an evidence-based antiemetic program adapted to the patient’s pro-posed chemotherapy regimen.

• Teaching for patients around their specific antiemetic regimen, including compliance issues

• Developing individualized patient medication calendars when required to assure appropriate use of antiemetic medications.

• Subsequent followup of individual patients (via tele-phone) to assess the level of CINV control, utilizing a standardized assessment tool

• Support to individual clinical pharmacists in obtaining additional prescribing authorization (APA) status, with the aim of working to full scope of professional practice (See Figure 2).

Evaluation methods included a review of overall clinical work-load statistics in order to validate total hours required to consistently provide clinical pharmacist services. Medication reconciliation statistics, including the number of discrepan-cies identified, were tabulated, and individual patients’ nausea and vomiting control was reviewed. Patients and healthcare team members were surveyed to assess their perceptions of the value of the expanded pharmacist role.

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FIGURE 2. Pharmacists’ expanded scope of practice in canada

Adapted with permission © Canadian Pharmacists Association September 2014

Provide emergency prescription refills

Renew/extend prescriptions

Change drug dosage/formulation

Make therapeutic substitution

Prescribe for minor ailments/conditions

Initiate prescription drug therapy

Order and interpret lab tests

Administer a drug by injection

Regulated Pharmacy Technicians

BC AB SK MB ON QC NB NS PEI NL NWT YT NU

Implented in jurisdiction Pending legislation or regulation or policy

Not implemented

Province/Territory

6,7

6

6,7

11

6,7

6,7

6

6,8

42

1

5

9 2

3

Expanded Scope

6,7

Pharmacists' Expanded Scope of Practice in Canada

1. AB: pharmacists in Alberta who have “additional prescribing authority” can prescribe a Schedule F drug (prescription-only), including those for the treatment of minor ailments

2. SK, NS & PEI: only as part of assessment and prescribing for minor ailments3. MB: as Continued Care Prescriptions under section 122 of the Regulations to the Pharmaceutical Act4. ON: restricted to prescribing specified drug products for the purpose of smoking cessation5. ON: administration of influenza vaccination to patients five years of age and older; administration of all other injections and inhalations for

demonstration and educational purposes6. QC: pending Orders in Council (activity enabled by passage of Bill 41, an Act to amend the Pharmacy Act, December 8, 2011; regulation for this

activity was planned for September 3, 2013, however it was postponed by Orders in Council on August 22, 2013)7. QC: when authorized by a physician by means of a “collective prescription” (i.e., collaborative practice agreement)8. QC: for demonstration purposes only9. NB: prescribing constitutes adapting, emergency prescribing or within a collaborative practice; independent prescribing or as part of minor

ailments prescribing is pending10. PEI: implementation is pending pharmacist education and the development of standards of practice 11. NS: limited to non-formulary generic substitution demonstration and educational purposes

© Canadian Pharmacists Association September 2014

10

2












Not implemented

Province/Territory

6,7

6

6,7

11

6,7

6,7

6

6,8

42

1

5

9 2

3

Expanded Scope

6,7








10

2


2. SK, NS & PEI: only as part of assessment and prescribing for minor ailments

3. MB: as Continued Care Prescriptions under section 122 of the Regulations to the Pharmaceutical Act

4. ON: restricted to prescribing specified drug products for the purpose of smoking cessation

5. QC: pending Orders in Council (activity enabled by passage of Bill 41, an Act to amend the Pharmacy Act, December 8, 2011; regulation for this activity was planned for September 3, 2013, however it was postponed by Orders in Council on August 22, 2013)

6. QC: when authorized by a physician by means of a “collective prescription” (i.e. collaborative practice agreement)

7. NB: prescribing constitutes adapting, emergency prescribing or within a collaborative practice; independent prescribing or as part of minor ailments prescribing is pending

8. NL: limited to nonformulary generic substitution

5,6

53

5,6

5,6 8

5,61

5,6 7 2 242












Not implemented

Province/Territory

6,7

6

6,7

11

6,7

6,7

6

6,8

42

1

5

9 2

3

Expanded Scope

6,7








10

2












Not implemented

Province/Territory

6,7

6

6,7

11

6,7

6,7

6

6,8

42

1

5

9 2

3

Expanded Scope

6,7








10

2

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49 patient followup phone calls were completed to assess acute and delayed CINV. The majority of patients, 31(63%), denied experiencing any CINV episodes, suggesting that both the teaching and medications provided had been successful in managing these side effects. Thirteen patients (27%) reported minimal episodes of nausea, with most indicating a severity of 1 or 2 out of 10, and 2 patients (4%) indicating a severity of 5 to 10. Three patients (6%) reported actual vomiting (1, 4 and 10 total episodes).

Healthcare team survey resultsIn March 2014, a paper and electronic survey was distrib-uted to JACC clinical staff to evaluate overall satisfaction with the clinical pharmacist services. Clinicians were asked to rank a series of questions as well as provide responses to several open-ended queries. A total of 8 responses were received, expressing overwhelmingly positive feedback. One hundred percent of respondents indicated “strongly agree” to the following questions: “Overall I found the pharmacist’s services to be helpful to the healthcare team” and “The clinical pharmacist’s services in the new patient clinics should be continued.”

Patient survey results In June 2014, a patient satisfaction survey was distributed to all new patients who had seen a clinical pharmacist (Table 2). Patients were asked to rank a series of questions as well as provide comments to a series of open-ended queries. A total of 17 responses were received, again expressing over-whelmingly positive feedback. Over 94% of respondents indicated “strongly agree” to 2 questions in the survey: “Overall I found the pharmacist’s services to be helpful” and “The information provided to me by the pharmacist was helpful,” with the remaining 6% indicating “agree.” Although a key focus of the initial study was CINV follow-up, patients indicated that they had discussed numerous other clinical issues with the pharmacist. One hundred per-cent of respondents indicated that the amount of time spent with the pharmacist appeared to be “just right.”

Status of successful obtaining of aPaEach of the 3 pharmacists participating in the project was successful in obtaining APA status for the province of Alberta on first attempt. Individually they stated that within their clinical activities, they felt considerably more fulfilled and involved thanks to increased day-to-day interaction with patients. They also commented that such involvement had greatly facilitated their understanding of the complexities of oncology drug prescribing and had enhanced their ability to successfully obtain the higher-level pharmacy certification.

dIscussIonOncology patients receiving modern chemotherapy present a therapeutic challenge for clinicians and frequently require interactions with multiple healthcare professionals.10,11,12 The current emphasis on ambulatory care is moving patients toward community-based services.5,6,12 As treatment protocols become increasingly complex, it is essential that the expertise

of all healthcare professionals be fully utilized.4,5 As part of this shift, many believe that introducing clinical pharmacy services directly into ambulatory care processes will facilitate multidisciplinary care and improve quality of care.6,11,12

New patients attending a multidisciplinary clinic where clinical pharmacists are physically present benefit from the healthcare expertise of a cohesive care team.3,5,6 Clinical pharmacists provide patients upfront education on their current medications and the proposed chemotherapy, and emphasize the importance of adherence to prescribed regi-mens. Pharmacist screening for drug-drug, drug-food and drug-disease interactions has the potential to decrease med-ication errors and avoid significant adverse events.1,2,3 In addition, having the clinical pharmacist available in real time facilitates immediate responses to questions from other mem-bers of the healthcare team, as well as efficient liaison between the new-patient clinic and the pharmacy dispensary.2,3

There is a paucity of literature concerning the role and efficacy of ambulatory oncology clinical pharmacists. Johnson et al. documented that providing direct clinical pharmacy

TablE 2. Patient survey results

Rank the statements below on the following scale: 1=strongly disagree; 2=disagree; 3=neutral; 4=agree; 5=strongly agree; 6=not applicable. Expressed in %.

1 to 3 4 5 6 Total responses

1. Overall I found the pharmacist’s services to be helpful.

0 5.88 94.12 0 17

2. The pharmacist asked me about all medications (including over-the-counter medication) I was taking.

0 5.88 94.12 0 17

3. The pharmacist asked me about herbal/alternative treatments I was taking.

0 17.65 70.59 11.76 17

4. The pharmacist answered questions I had about my medications.

0 17.56 82.35 0 17

5. The pharmacist provided information to me about drugs needed to prevent nausea and vomiting while I am on chemotherapy.

0 11.76 82.35 5.88 17

6. I appreciated receiving a followup phone call from the pharmacist.

0 11.76 82.35 5.88 17

7. The pharmacist helped me to manage my nausea and vomiting symptoms.

0 11.76 70.59 17.65 17

8. I asked the pharmacist questions about symptoms other than nausea and vomiting.

0 5.88 88.24 5.88 17

9. The information provided to me by the pharmacist was helpful.

0 5.88 94.12 0 17

TablE 1. Medication reconciliation statistics (aug 2013 to july 2014)

Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Total

Completed 28 41 36 30 24 24 23 27 28 23 20 21 325

Discrepancies 55 111 108 117 77 105 100 82 79 85 69 77 1065


care in the ambulatory setting appeared to reduce negative therapeutic outcomes by 53% to 63%.13 Wong et al, studying a 1000-bed university teaching hospital, determined that 29% of clinical pharmacist interventions were of potentially high clinical significance, whereas 55% were of moderate clinical significance. They found a 74% positive clinical outcome following the clinical pharmacist intervention, while 23% of interventions could not be evaluated at the time of occurrence.1

The present study focused primarily on CINV, where a predetermined stratification of the emetogenicity of che-motherapy regimens can be linked via algorithm to the most appropriate antiemetic combination.8,9 However, despite the appropriate selection of prophylactic antiemet-ics, some patients still experience breakthrough CINV.9 Involving the clinical pharmacist early on can play a critical role in identifying a high risk for breakthrough CINV.10 Similarly, the clinical pharmacist telephone followup may also uncover patients who would otherwise delay reporting symptoms.8,9 Many patients still consider CINV an inevita-ble consequence of cancer chemotherapy. The pharmacists in the study heard many patients express significant relief after being informed of the reduced incidence of CINV accompanying appropriate antiemetic usage. Results show-ing that 90% of patients report no or only minor CINV would tend to substantiate the value of the clinical pharma-cist’s involvement in this area. Although there was no ran-domized control group in our study, these results compare favourably with what others have reported.2,7,8

There also was an impression that the pharmacist’s avail-ability and followup made patients more likely to relay concerns regarding poor antiemetic control. Although this study provides no randomized evidence, there appeared to be an improvement in adherence to antiemetics secondary to pharmacist counselling and availability. The clinical pharma-cists’ tools for increasing compliance include the supplying of clear and concise instructions in the clinic, repetition of instructions at the time of the telephone followup, and the provision of written personal medication instructions as required.11,12 This dialogue and trust-building with patients seemed to carry over in the self-reporting of complementary and alternative medicine usage (CAM). Studies have shown that over 50% of oncology patients are likely using CAM, but are frequently reluctant to discuss this with their oncologist.14 It was the team’s impression that patients did not hesitate to the same degree with the clinical pharmacist, and that self-reporting of CAM increased once the program was in place.

The overwhelmingly positive survey responses indicated that the majority of team members and patients were very satisfied with the amount and timeliness of information provided. In this respect, the value of the pharmacists’ followup telephone protocol and visits cannot be over-emphasized.11 Patients would otherwise have had to revisit their physician or nurse to obtain such advice.12 Team members consistently reported that the pharmacists’ ready availability improved efficiency by easing the work-load of the other clinic staff in medication education and antiemetic followup.5,7,8,11

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conclusIonThe pilot project implemented at the JACC at the request of AHS demonstrated the benefits of an increased and integrated role for pharmacists in community oncology. The role responds to new challenges and pressures that accompany greater demand for cancer care services, growing complexity of cancer drug regimens, and a focus on ambulatory cancer care. All healthcare professionals are being encouraged to work to their full scope of practice in order to improve efficiency, quality and access to care. Pharmacists welcome the shift and many are undertaking the additional certification that enables an expand-ed role. In the JACC pilot project, the clinical pharmacists expressed increased job satisfaction, and all 3 succeeded in obtaining APA status. Many individuals who enter pharmacy are strongly motivated to help patients directly and may be disappointed when they spend a majority of time in the dispen-sary, with little face-to-face patient contact. Their increased interactions as part of the multidisciplinary team have rein-forced the image of the entire pharmacy department at the JACC. While the current study focused primarily on CINV control, other areas in clinical oncology in which benefit from direct involvement of clinical pharmacists has been demon-strated include smoking cessation, anticoagulation, anemia and pain management, fluid and electrolyte replacement therapy ordering, and constipation/diarrhea, skin toxicity, stomatitis/mucositis management.1,2,5,15,16 The increasing availability of additional prescribing authorization will further augment the value of the services clinical pharmacists can provide.

references1. Wong SW, Gray ES. Clinical pharmacy services in oncology clinics. J Oncol Pharm

Practice 1999;5: 49–54.2. Ruder AD, Smith DL, Madsen MT, et al. Is there a benefit to having a clinical

oncology pharmacist on staff at a community oncology clinic? J Oncol Pharm Practice 2011;17:425-32.

3. Shah S, Dowell J, Greene S. Evaluation of clinical pharmacy services in a hematology/oncology outpatient setting. Ann Pharmacother 2006;40:1527-33.

4. Erikson C, Salsberg E, Forte G, et al. Future supply and demand for oncologists: Challenges to assuring access to oncology services. J Oncol Pharm Practice 2007;3:79-86.

5. Sessions JK, Valgus J, Barbour SY et al. Role of oncology clinical pharmacists in light of the oncology workforce study. J Oncol Pharm Practice 2010; 6:270-2.

6. Caselnova DA, Dizerba SH, O’Neill MS et al. Implementing clinical pharmacy services in an outpatient oncology clinic. Am J Hosp Pharm 1985;42:1348-52.

7. Carrington CV, Cottrell N, Kirkpatrick C. The impact of the day care pharmacist on chemotherapy induced nausea and vomiting: A prospective, observational study. Asia-Pacific J Clin Oncol 2012;8:124.

8. Martin JK, Norwood MB. Pharmacist management of antiemetic therapy under protocol in an oncology clinic. Am J Hosp Pharm 1988;45:1322-8.

9. Basch E, Prestrud AA, Hesketh PJ et al. Antiemetics: American Society of Clinical Oncology Clinical Practice Guideline Update. J Clin Oncol 2011;29:4189-98.

10. Chan A, Shih V, Chiang J, et al. Clinical pharmacy services and research for lymphoma patients at a cancer center. J Oncol Pharm Practice 2013;19:24-30.

11. Ryan N, Chambers C, Ralph C, et al. Evaluation of clinical pharmacists’ follow-up service in an oncology pain clinic. J Oncol Pharm Practice 2013;19:151-8.

12. Delaney L, Chambers C, Roldan G, et al. A feasibility study to assess the integration of a pharmacist into neurooncology clinic. J Oncol Pharm Practice 2009;15:79-85.

13. Johnson JA, Bootman JL. Drug related morbidity and mortality and the economic impact of pharmaceutical care. Am J Health Syst Pharm 1997;54:554-8.

14. Brigden ML. Unproven cancer therapies. West J Med 1995; 163:463-9. 15. Fairchild A, Gagnon L, Pituskin E, et al. Optimizing pain relief in a specialized

outpatient palliative radiotherapy clinic: Contributions of a clinical pharmacist. Supportive Care in Cancer 2010;18:S162.

16. Dent LA, Harris KJ, Noonan CW. Randomized trial assessing the effectiveness of the pharmacist delivered program for smoking cessation. Annals of Pharmacotherapy 2009; 43:194-201.

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