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ORIGINAL ARTICLES

An Off-Site Clinical Service in : Development and 1-Year Outcomes Joseph P. Vande Griend, PharmD; Joseph J. Saseen, PharmD; Debra Bislip, MD; Gina Moore, PharmD, MBA; Colleen Conry, MD

BACKGROUND AND OBJECTIVES: Clinical are a part including teaching, consultation, and of integrated teams and provide clinical medication direct patient care.1,2 Support for the recommendations for family . On-site clinical pharmacy role of clinical pharmacists on inter- services are common in family medicine. This model may not be professional teams within the health the most effective or efficient way to provide clinical pharmacy care system was provided in a state- services in a small practice or in a remote location. The objec- ment from the US General tives of this study were to describe the development of an off-site who noted that “Utilization of phar- clinical pharmacy service and to describe the 1-year clinical im- macists as an essential part of the pact of this service. health care team to prevent and METHODS: The University of Colorado Park Meadows Family Medi- manage in collaboration with cine is located approximately 15 miles from the Anschutz other clinicians can improve qual- Medical Campus. In July 2011, a clinical implemented ity, contain costs, and increase ac- clinical pharmacy services with the goal of providing medication cess to care.”3 expertise primarily using an off-site model. The clinical pharmacist Pharmacist-provided patient care prospectively screened patients with appointments and provided has demonstrated favorable effects medication recommendations in the electronic for across various patient outcomes, providers to consider at the patient appointment. health care settings, and disease states.4 The role of a clinical pharma- RESULTS: For the first 12 months, the clinical pharmacist spent 118 hours providing the clinical pharmacy service. A total of 315 cist has become increasingly impor- medication recommendations were made for 123 patients; 69.8% tant in interprofessional care teams were implemented. Forty-nine vaccinations were administered, and within the patient-centered medical 5 24 potentially dangerous major drug-drug interactions were iden- home (PCMH). Pharmacists have tified and resolved. Thirty-one unnecessary high-cost drugs were been identified as ideal team mem- discontinued, resulting in estimated annual savings of $52,215.36. bers who can perform comprehensive medication reviews, resolve CONCLUSIONS: Our data indicate that clinical pharmacy servic- medication-related problems, opti- es can be implemented for smaller remote family using an mize complex medication regimens, offsite model. Within this model, clinical pharmacy interventions design adherence programs, and rec- optimized medication use, managed serious drug interactions, and ommend cost-effective .6 resulted in cost avoidance. The pharmacist can also serve as (Fam Med 2014;46(5):348-53.) a valuable resource to improve ap- propriate medication use within the

linical pharmacists function- clinically meaningful medication rec- From the Department of Clinical Pharmacy, ing as part of an interprofes- ommendations. In family medicine Skaggs School of Pharmacy and Pharmaceutical sional health care team can training programs, clinical Sciences (Drs Vande Griend, Saseen, and C Moore) and the Department of Family Medicine improve patient care by addressing pharmacists have been functioning (Drs VandeGriend, Saseen, Bislip, and Conroy), medication issues and providing in a variety of roles for many years, University of Colorado.

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health care system through collab- provided by one clinical pharma- pharmacist was at the clinic) or via orative drug therapy management, cist (the first author, JVG) who has communication through the EMR. medication reconciliation, and other 2 years of postgraduate pharmacy For this study, data were collect- strategies.5 residency training, including 1 year ed on all patients that the clinical For small clinics, or of specialty training in family medi- pharmacist provided medication rec- primary care clinics located in re- cine. In total, the clinical pharma- ommendations for between July 1, mote areas, on-site clinical pharma- cist spent 118 hours providing the 2011 and June 30, 2012. Data col- cy services may not be feasible. The clinical pharmacy service over the lected included age, number of medi- advent and proliferation of the elec- 1-year time period; 70.5 hours were cations, renal function, and presence tronic medical record (EMR) makes conducted on-site at the clinic, and of diabetes, hypertension, chronic ob- the possibility of an off-site clinical 47.5 hours were conducted off-site. structive lung disease, heart failure, pharmacy service possible. Within The location utilized for the off-site or . The number and an off-site model, a clinical pharma- portion of the clinical pharmacy type of medication recommendations cist can review medication regimens, service was the office of the clinical made and the result of the recom- evaluate laboratory data, review of- pharmacist, which has a phone and mendations was also collected and fice visit notes, and send medication access to the EMR. The office is lo- analyzed. recommendations in the EMR to the cated on the University of Colorado provider. Family physicians can also Anschutz Medical Campus, approxi- Statistical Analysis send medication questions or consul- mately 15 miles from the University Descriptive statistics were used and tations electronically to the clinical of Colorado Park Meadows Family are presented as mean values (+/- pharmacist within the EMR. When Medicine Clinic. standard deviation) and percentages. needed, the off-site clinical pharma- The EPIC™ (Verona, WI) EMR is cist can contact patients or providers utilized by the University of Colora- Results over the phone and vice versa. All do health care system. As part of the The majority of the clinical pharma- this can be performed at any location clinical pharmacy service, the clini- cy service was provided on-site at the with EMR access via a computer. cal pharmacist utilized the EPICTM clinic (59.7%). As time and experi- Despite increased roles for clinical EMR to prospectively review the ence with the clinical pharmacy ser- pharmacists in primary care, expan- medication regimens of patients with vice progressed, the clinical service sion of interprofessional teams with- a clinic appointment for each upcom- shifted more off-site as was intend- in the PCMH, and increased use of ing week. This was done either at ed. After the initial 6 months of the the EMR, there is a lack of published the clinic or at the off-site office of project, over 70% of the service was studies describing an off-site clini- the clinical pharmacist. The clinical provided off-site. The clinical phar- cal pharmacy service. This research pharmacist did not review all pa- macist provided 128 Clinical Phar- project describes the development of tients with an appointment, but se- macy Consultation notes in the EMR an off-site clinical pharmacy service, lected patients who were thought to for provider consideration in a total and summarizes the 1-year clinical benefit most from medication review of 123 patients. The demographics results of this service. (eg, those with diabetes, those with of patients whose provider received multiple medications). There were no a clinical pharmacist note are shown Methods specific criteria for patient selection; in Table 1. Approximately one in six This study was approved by the Col- the clinical pharmacist utilized clini- (17%) consultation notes resulted orado Multiple Institutional Review cal judgment. For patients selected, from specific provider requests. The Board. The University of Colorado the clinical pharmacist performed a majority of the consultation notes re- Park Meadows Family Medicine comprehensive medication review sulted from prospective comprehen- Clinic was the clinic location for the (CMR) prior to the patient appoint- sive medication reviews performed clinical pharmacy service. At the ment and placed a “Clinical Pharma- prior to the patient’s appointment. time this project initiated, this clinic cy Consultation” note in the patient’s A total of 315 medication recom- provided approximately 100 patient EMR when a drug therapy problem mendations were made in the 128 visits per week spread among three was identified and a medication rec- consultation notes (approximate- family providers and three ommendation was warranted. The ly 2.5 recommendations per note). nonphysician providers (two nurse provider could then review the note The drug therapy problems identi- practitioners and one physician as- and consider it, if desired. No con- fied and most common medication sistant), a total of 5.4 full-time em- sultation note was written if no drug recommendations made are catego- ployees. This clinic did not have and therapy problems were identified af- rized in Table 2. Because there were had not previously had clinical phar- ter CMR. The clinical pharmacist so many different recommendations macy services. also received consultations for CMR made, the second column of Table 2 The clinical pharmacy service from providers in person (when the only describes the most common was initiated in July 2011 and was recommendations for each category

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Table 1: Demographics of Patients Receiving a Clinical during the study period that had not Pharmacist Medication Recommendation* been restarted as of July 1, 2013 (Ta- ble 3). As of this date, these medi- Mean age (years) 65.4 (+/- 10.8) cations had not been prescribed for Mean number of medications 10 (+/- 5.6) at least 12 months and possibly as long as 24 months. Table 3 lists the Type 2 diabetes 41/123 (33%) Average Wholesale Price (AWP) per Hypertension 98/123 (70.7%) month for the discontinued medica- Existing vascular disease 19/123 (15.4%) tions. Medication prices were derived ® 7 Existing COPD 3/123 (2.4%) from Red Book Online . Assuming all medications were stopped for 12 GFR < 60 mL/min 48/123 (39%) months, the annual direct cost sav- GFR < 30 mL/min 2/123 (1.6%) ings for stopping these unnecessary, Existing heart failure 1/123 (0.8%) duplicate, or potentially harmful medications could potentially be up * n=123 unique patients to $52,215.36. COPD—chronic obstructive pulmonary disease GFR—glomerular filtration rate Discussion The results of this study demon- of drug therapy problem. Overall, comprehensive medication review strate that an off-site clinical phar- 69.8% (n=220) of medication recom- (197/281), 67.6% versus 70.1%. macy service is feasible and can be mendations were implemented by Multiple medications were iden- effective but may require a signifi- the medical provider. Acceptance of tified as unnecessary, duplicate (two cant initial investment of time on- the most common recommendations or more active medications with the site. The optimal amount of on-site was very high (third column of Table same indication or mechanism), or time needed is unknown. Admittedly, 2). The acceptance rate of medica- potentially harmful. These were the clinical pharmacist in our study tion recommendations was similar medications the provider noted spent more time on-site during the when the consultation was request- the patient taking and then subse- first 6 months of the service than ini- ed by the provider (23/34) compared quently discontinued as a result of tially intended. This is most likely to when prospectively identified by the Clinical Pharmacy Consultation. attributable to the fact that this type the clinical pharmacist during the There were 31 medications stopped of service had not previously been

Table 2: Summary of Drug Therapy Problems

Type of Drug Therapy Problem (n) Most Common Recommendations n, % Accepted Needs additional therapy (151) Vaccine 94, 52% HMG CoA reductase inhibitor 21, 95% Antidiabetic agent 7, 14% Blood pressure lowering agent 3, 66% Unnecessary drug (35) Triglyceride lowering not needed 13, 85% Extended-release niacin not indicated 7, 100% Ezetimibe not indicated 6, 100% Drug interaction (24) Simvastatin interaction 21, 100% Wrong dose (22) Blood pressure drug dose too high/low 12, 75% Diabetes drug dose too high/low 5, 80% Lab needed (22) Vitamin D 9, 44% DEXA 4, 25% Cost (19) Brand-only switched to different generic 14, 86% Inappropriate drug (10) Unsafe in patient 65 years or older 10, 90% Adverse drug reaction (9) Variety of reactions identified 9, 89% Wrong drug (9) Red yeast rice when statin indicated 1, 100% Metamucil for opioid-induced constipation 1, 100% Duplicate therapy (7) Aspirin/clopidogrel, ACEi/ARB 4, 50% Other (7) Non-adherence, medication reconciliation 4, 100%

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Table 3: Medications Discontinued and Estimated 1-Year Cost Savings

Medication Number Discontinued Total AWP/Month ($) Lovaza™ (omega-3-acid ethyl esters) • 2 capsules twice daily 2 472.78 • 1 capsule twice daily 3 354.60 Gemfibrozil 5 163.88 Fenofibrate • Tricor™ 48 mg 1 69.90 • Tricor™ 145 mg 2 419.72 • Fenofibrate 54 mg 1 23.70 • Triglide™ 160 mg 1 239.70 Niaspan™ (niacin controlled release) • Niaspan™ 1,000 mg daily 3 682.20 • Niaspan™ 500 mg daily 3 385.20 Zetia™ (ezetimibe) 10 mg 4 747.60 Terazosin 5 mg 1 43.50 Cymbalta™ (duloxetine) 60 mg 1 238.20 Clopidogrel 75 mg 1 130.80 Triamterene/Hydrochlorothiazide 37.5/25 mg 1 11.70 Colcrys™ (colchicine) 0.6 mg 1 178.20 Vytorin™ (ezetimibe/simvastatin) 10/20 mg 1 189.60 Annual Estimated Savings $52,215.36

AWP—average wholesale price; when more than one generic option was available, the lowest cost product was utilized to estimate cost, and all prices were obtained from the 90-unit or 100-unit package size. developed and that only one provid- the patient’s provider through the appointment, and the extra review er at the Park Meadows clinic had EMR is lacking. by the pharmacist in this study was previous experience working with The demographics described in Ta- very fruitful, resulting in many vac- a clinical pharmacist. Similar stud- ble 1 represent the type of patient cines administered and multiple un- ies of clinical pharmacists working that would be expected to benefit necessary medications discontinued. outside of the primary care clinic to from a more intense medical in- Overall, all the drug therapy prob- provide clinical pharmacy services tervention that includes CMR per- lems identified and medication rec- have been described.8-11 Within these formed by a clinical pharmacist. The ommendations made in this study models, the clinical pharmacists had most common drug therapy problem can be done through the EMR at an access to the patient’s medical infor- identified in these patients was the off-site location with no need to be mation, could contact the patients need for an additional therapy. The physically at the clinic. by phone, and communicated with most common recommendation for Over 80% of the clinical pharma- the patient’s provider through the this drug therapy problem was the cy medication recommendations in electronic medical record. However, need for a vaccination that was in- this study were made to the provider in most of these models, the clini- dicated but not yet administered. without the request of the provider. cal pharmacist targeted a specific Identifying unnecessary drugs and Despite the fact that the provider did disease state.8-10 In contrast to our recommending discontinuation was not request a large majority of the study, these clinical pharmacists also addressed frequently by the medication recommendations, they were not established in a specific clinical pharmacist. Reviewing the were well received, and there was a clinic but worked with health plan EMR to evaluate whether a medica- high overall acceptance rate (~ 70%). members to provide the service to tion is indicated, or whether it can The acceptance rate was similar re- a large group of covered members. be stopped without harm, can take gardless of who initiated the clini- Published literature describing the a significant amount of time but can cal pharmacy consultation. Similarly, establishment of a clinical pharmacy be extremely valuable when a med- the acceptance rate of the more criti- service in primary care with the goal ication is safely stopped. The need cal recommendations (ie, clinically of providing off-site comprehensive for vaccines and the evaluation of relevant drug interactions, vaccina- medication review and making medi- potentially unnecessary drugs are tions, recommendations to improve cation recommendations directly to easily overlooked in a busy clinic lipids, blood sugar, and blood

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pressure, and recommendations to between a community pharmacist administration also generated ad- stop high cost/unnecessary drugs) and a physician.22 ditional revenue for the clinic. The was very high. Our acceptance rate In our model, several key ele- addition of the 19 statins, two anti- of recommendations is similar to ments reflecting effective collabora- hypertensives, one antidiabetic, and other published clinical pharmacy tion between the clinical pharmacist one bisphosphonate also likely had studies, where acceptance rates for and the provider were present and a positive impact on health care out- recommendations from a pharmacist likely contributed to the high accep- comes, but this was not quantified to a provider have ranged from 42% tance rate of recommendations. If us- given the small number of patients to 90%.12-20 Recommendations made ing our model to establish an off-site involved. from an off-site contracted medica- clinical pharmacy service within a This 1-year project was deemed tion therapy management service family medicine clinic, the develop- successful by the University of Col- utilizing a facsimile correspondence ment of professional relationships orado. The Department of Family that is forwarded to a provider15 and through face-to-face interactions be- Medicine decided to fund a second recommendations from pharmacists tween the clinical pharmacist and year of this off-site clinical phar- in a community pharmacy14 appear providers, a pharmacist with clinical macy service. However, in the sec- to have a lower provider acceptance experience, and access to the elec- ond year, the service was expanded rate (<50%). Recommendations made tronic medical record appear impor- to an additional off-site clinic. This from pharmacists in long-term care, tant to optimize success. Ongoing second clinic is the University of primary care, or the setting on-site face-to-face interactions be- Colorado Boulder Family Medicine have higher acceptance rates (55%– tween the clinical pharmacist and Clinic (Boulder, CO), which is locat- 90%) and are comparable to our re- providers are also likely necessary ed approximately 38 miles from the sults.12,13,16-20 to maintain the successfully estab- main university campus. This mod- Our high acceptance rate is likely lished collaborative working rela- el of establishing and providing off- due to several factors that are very tionship. site, clinical pharmacy services is important to consider when devel- The clinical pharmacist saved very relevant and applicable to cur- oping an off-site clinical pharmacy more money than what it cost to pro- rent PCMH initiatives. It may allow service. A recent meta-analysis de- vide the service, resulting in a posi- a clinical pharmacist to provide ser- scribes eight key elements reflect- tive financial impact to the health vices to multiple clinics in an effi- ing effective collaboration between a care system. Assuming an annual cient and effective manner. Further pharmacist and a primary care pro- expense of $150,000 (both salary research is needed to streamline the vider when providing a comprehen- and benefits) for a clinical pharma- process of identifying patients who sive medication review.21 These key cist, the corresponding hourly rate would benefit from a clinical phar- elements include (1) a pharmacist is approximately $72 for a 40-hour macist medication review, as well as with clinical experience, (2) having workweek. Based on this, the total work toward increasing the number the patient’s usual pharmacist do cost of providing the clinical phar- of provider-initiated clinical pharma- the review, (3) pharmacist access to macy service was only $8,500 for cy consultations. the medical record, (4) patient inter- the 118 hours of clinical pharmacist view by the pharmacist, (5) time spent delivering the service Conclusions of patients to the pharmacist from during the first 12 months. Stop- Clinical pharmacy services were suc- the primary care provider, (6) face-to- ping the 31 unnecessary, duplicate, cessfully established in a small fam- face meeting between the pharmacist or potentially harmful medications ily medicine clinic using primarily an and primary care provider to discuss as a result of clinical pharmacist off-site clinical pharmacy consulta- the pharmacists’ medication recom- recommendation potentially result- tion model. The acceptance rate of mendations, (7) implementation of ed in over $50,000 of estimated cost clinical pharmacy recommendations an action plan to follow through on savings to the health care system. was high, and this clinical pharma- accepted recommendations, and (8) Therefore, the return on investment cy service had positive financial and follow-up. The meta-analysis found to the health care system from just health care outcomes. This unique a direct positive association between the stopped medications alone was model of delivering clinical pharma- the number of key elements included estimated to be over $40,000 for cy services is an efficient and effec- in the clinical service and the recom- 1 year after accounting for the clini- tive way to enhance interprofessional mendation implementation rate. In cal pharmacist expense. The clinical care in small clinics or clinics located another study, open communication pharmacy service also had a posi- in a remote location. However, a sig- with face-to-face visits directly with tive impact on health care quality. nificant initial on-site time invest- physicians was identified as impor- As a result of clinical pharmacist ment to establish this type of off-site tant when establishing a successful recommendations, the clinic ad- service is needed. collaborative working relationship ministered 49 vaccinations. Vaccine

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ACKNOWLEDGMENTS: Financial support 8. Magid DJ, Ho PM, Olson KL, et al. A multi- 16. Bondesson A, Holmdahl L, Midlov P, Hoglund was received from the Primary Care Strate- modal blood pressure control intervention in P, Andersson E, Eriksson T. Acceptance and gic Funding Program through the University three health care systems. Am J Manage Care importance of clinical pharmacists’ LIMM- of Colorado School of Medicine, University of 2011;17:e96-103. based recommendations. Int J Clin Pharm Colorado Hospital, and University Physicians 9. Merenich JA, Olson KL, Delate T, Rasmussen 2012;34:272-6. Inc. J, Helling DK, Ward DG. Mortality reduction 17. Nishtala PS, McLachlan AJ, Bell JS, Chen TF. This paper was presented at the Society of benefits of a comprehensive cardiac care pro- A retrospective study of drug-related problems Teachers of Family Medicine 2012 Conference gram for patients with occlusive coronary ar- in Australian aged care homes: medication on Practice Improvement, Greenville, SC. tery disease. 2007;27:1370-8. reviews involving pharmacists and general practitioners. J Eval Clin Pract 2011;17:97-103. CORRESPONDING AUTHOR: Address corre- 10. Sandhoff BG, Nies LK, Olson KL, Nash JD, spondence to Dr Vande Griend, University of Rasmussen JR, Merenich JA. Clinical phar- 18. Leikola SN, Virolainen J, Tuomainen L, Tu- Colorado, Departments of Clinical Pharmacy macy cardiac risk service for managing pa- ominen RK, Airaksinen MS. Comprehensive and Family Medicine, Skaggs School of Phar- tients with coronary artery disease in a health medication reviews for elderly patients: find- macy and Pharmaceutical Sciences, Mail Stop maintenance organization. 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