The added value of a pharmacist in identifying drug-related needs of patients in an adult ambulatory cystic fibrosis clinic

Sabrina Chan, Elizabeth Tullis, Daniel Cortes 2013 North American Cystic Fibrosis Conference October 17-19, 2013

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Study Rationale

• Large body of literature evaluating pharmacists’ role in ambulatory clinics

• Examples of outcomes measured: – Hospitalization rates – Improvement in laboratory results e.g. blood pressure,

warfarin monitoring – Patient/clinician satisfaction with pharmacists interventions !

• The added value of a pharmacist in an adult CF ambulatory clinic has not been studied

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Research objectives

1) To compare the number, types, and clinical significance of drug therapy problems (DTPs) identified by the pharmacist (RPh) and standard of care (SOC) in an adult

ambulatory CF clinic !2) To quantify RPh recommendations and classify patient

care services provided by RPh

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Standard clinic visit vs. study visitPatient

Nurse

SOC: Respirologist or

Nurse Practitioner

Respiratory therapist Dietician

Physiotherapist etc.

Study Patient

Nurse

SOC

Respiratory therapist Dietician

Physiotherapist etc.

RPh

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Methods

Documented: 1)DTP identified 2)DTP type 3)Self-rated DTP clinical significance: minor, moderate, major

RPh/SOC discussion

Patient

Nurse

SOC

RPh

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Drug Therapy Problem (DTP)Undesirable event experienced by a patient which

involves or is suspected to involve drug therapy

Types of DTPs: 1) Unnecessary drug therapy 2) Additional drug therapy required 3) Ineffective drug 4) Dose too low 5) Dose too high 6) Adverse drug reaction 7) Noncompliance / nonadherence

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DTP Clinical Significance: Major – DTPs requiring interventions

that prevent detrimental effect Moderate – DTPs requiring

interventions leading to moderate benefit to patient

Minor – DTPs requiring interventions assumed to have little clinical importance for the patient

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Examples of CF-related DTPs

Drug-therapy problem (DTP) DTP Type Clinical significance

Patient exhibiting signs and symptoms of a pulmonary exacerbation ! requires IV antibiotics

Additional drug therapy required

Major

Patient takes tobramycin 160mg inhaled once daily instead of twice daily

Nonadherence Moderate

Patient experiencing mild constipation secondary to iron supplementation

Adverse drug reaction

Minor

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Results

Pharmacist recommendations: 57 (79% acceptance rate)

N=20 Pharmacist Standard of Care

DTPs identified / patient

Total DTPs (p=0.002)

4.0 ± 2.38 1.7 ± 1.87

Excluding same DTPs identified by both groups (p=0.001)

3.05 ± 1.9 0.75 ± 1.5

DTP Types Additional drug required (31%) Adverse drug reactions (25%)

Additional drug required (47%) Adverse drug reactions (24%)

Clinical significance

No significant association between clinical significance ratings and RPh/SOC.

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Discussion• Different types of issues identified by both groups • Distinct roles for pharmacist and SOC clinicians within the

clinic • High acceptance rate of pharmacist’s recommendations • Generalizability of findings Limitations

– Small sample size – Hawthorne effect – Clinical significance classification had poor inter-rater

reliability – Disease outcomes (i.e. FEV1) not measured

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Conclusions• Pharmacists can add value to an adult ambulatory CF

clinic by: – identifying additional drug therapy problems – collaborating with the clinic team – providing expertise with drug-related clinical activities

!• Future direction:

– identify, prioritize who may benefit most from pharmacist assessment