- Email: [email protected]
Pharmacists' Consultations Sought by Residents of a Retirement Community
RESEARCH
Pharmacists' Consultations Sought by Residents of a Retirement Community Jill E. Dischler, Joy B. Plein, and Elmer M. Plein
Objectives: To identify, in a retirement home population with access to pharmacists' consultations: (1) the medical conditions of patients served, (2) the primary reasons residents (patients) sought consultations, (3) the actions taken by pharmacists to resolve patient-perceived and pharmacist-detected problems, and (4) patients' perceptions of the usefulness of pharmacists' services. Design: For objectives 1,2, and 3, analysis of pharmacy records of consultations; for objective 4, mail survey of patients. Setting: A Seattlecontinuing care retirement community (CCRC) affiliated with the University of Washington School of Pharmacy for provision of pharmacy education and services. Patients: All independent-living residents of the CCRC who sought pharmacist consultation during the 6-year study period. Interventions: Advice to patients and coordination of care. Main Outcome Measures: Patients' medical conditions; reasons patients sought consultations; pharmacists' interventions; patients' perceptions of the value of services. Results: Pharmacists provided 564 consultations to 121 patients whose mean age was 84 years. The mean number of medical problems identified per patient was 4.8. Of 828 major reasons patients sought consultation, 57.4% were categorized as requests for primary care, 27.7% for drug information, 8.6% for medication management, and 6.5% for medication regimen review. Pharmacists responded with an average of 2.6 recommendations or interventions per consultation. Of the pharmacists' responses, 44.8% were categorized as primary care, 19.9% as drug information, 20.5% as regimen review, and 12.1% as medication management. Patients perceived the consultations to be highly valuable. Conclusion: If such services are available, retirement home residents will seek in-depth consultations with pharmacists on health and medication questions and problems, and they place a high value on pharmacists' advice. These services can be provided by community pharmacists with training in geriatric pharmacy.
JAm Pharm Assoc. 2001;41:709-17.
The "graying of America" is well recognized by health care professionals, the insurance industry, and the lay public. In 1998, 12.7% of the more than 270 million Americans were at least 65 years old and 1.5% were 85 or older.l The U.S . Bureau of the Census l has predicted (middle series prediction) that by 2010, 1.9% of the nearly 298 million people living in the United States will be 85 years or older, and that by 2030, 20% of the 347 million Americans will be at least 65 and 2.4% will be 85 or older. These projections present both challenges and opportunities for Received August 18, 2000, and in revised form November 28, 2000. Accepted for publication December 12, 2000. Jill E. Dischler, PharmD, is pharmacotherapist in ambulatory care and clinical assistant professor, College of Pharmacy, University of IllinoisChicago. At the time of this study, Dr. Dischler was a doctor of pharmacy student at the University of Washington, Seattle. Joy B. Plein, RPh, PhD, is professor of pharmacy; Elmer M. Plein, RPh, PhD, was Professor Emeritus of Pharmacy, School of Pharmacy, University of Washington, Seattle, and principal investigator on this study until his death in 1994. Correspondence: Joy B. Plein, RPh, PhD, School of Pharmacy, H375 HSB, Box 357630, University of Washington, Seattle, WA 98915. Fax: 206-543-3835. E-mail: [email protected].
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health care professionals. As patients advance in age, they must usually cope with increasing numbers of chronic and concomitant medical conditions.2.3 It is not surprising, therefore, that, on average, elderly adults use more drugs2.4-7 and suffer more adverse drug reactions (ADRs) than do younger patients. 7- 11 Concerns about ADRs and inappropriate prescribing for older patients have led physicians, pharmacists, and other health care professionals to investigate the appropriateness of prescribing for this population. 12- 22 Patients, alarmed by media reports, frequently express similar concerns in their conversations with pharmacists. In the late 1960s the focus of pharmacy education and practice began to shift away from a primary emphasis on dispensing and drug accountability to provision of clinical services such as prospective medication regimen review, patient counseling, and sharing drug information with other health care professionals. 23 .24 Over the last 30 years, pharmacists have taken on additional professional responsibilities, including patient assessment, treatment planning (pharmacist-initiated and/or initiated jointly with other providers), health promotion, and disease prevention. The concept of pharmaceutical care,23.25 first detailed in the early 1990s,
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makes the pharmacist directly responsible to the patient for the quality of the care she or he provides. This shift toward emphasizing clinical responsibilities began in hospitals and long-term care facilities . More recently, studies have shown the benefits of pharmacists' consultations with patients in outpatient settings24 including a family health center,26 community pharmacies,27 residential care facilities,28 anticoagulation clinics,29.3o and the patients' own homes3l and with patients being treated both with in-hospital and follow-up care.20 Since 1974, federal regulations for Medicare reimbursement to skilled nursing facilities have required pharmacist-conducted drug regimen reviews at least monthly for each resident. With a 30-year history of leadership in the development of pharmacotherapeutic services for residents of nursing homes and other long-term care facilities, the American Society of Consultant Pharmacists launched its Senior Care Pharmacy initiative in 1999. Under this strategic plan, senior care pharmacists' responsibilities include enhancing the quality of care and the quality of life for all older adults-whether they are community-dwelling or reside in institutions- "through the provision of pharmaceutical care and the promotion of healthy aging."32.33 This comprehensive approach to pharmacy's role is not site-dependent and is compatible with the goal of providing a continuum of care. The University of Washington School of Pharmacy (UW) and the Hearthstone, a continuing care retirement community34 (CCRC) in Seattle, initiated a collaborative learning/service program in January 1989. For well over a decade, the program has been training pharmacy students and practitioners in geriatric pharmacy and providing pharmacists' consultations to CCRC residents and professional staff. Faculty and students are generally present in the CCRC 2 days per week, where they provide consultations to residents of independent-living apartments (retirement home residents), nursing home residents, and assisted-living facility residents. The retirement home residents seek and manage their own health services, and the UW pharmacy services are available to them upon their own request. At the time the UW program was initiated at the Hearthstone, the authors planned this study to answer four questions: (1) What is the extent of patient-identified and pharmacist-identified medical and drug therapy problems in the retirement home population? (2) What are the reasons (self-perceived needs) that retirement home residents might seek consultative services of a pharmacist? (3) What actions might pharmacists take to respond to these patients' problems? (4) Will patients fmd the consultations helpful? In this article we answer these questions on the basis of data collected over a 6-year period from July 1989 through June 1995.
primary health and drug therapy problems perceived by independent-living patients who sought pharmacists' consultations; (3) the actions taken by pharmacists to resolve these problems as well as those detected by pharmacists; and (4) patients' perceptions of the usefulness of the pharmacists' services.
Methods Study Design For objectives 1,2, and 3 we performed a retrospective analysis of pharmacy records of all consultations provided to independent-living patients during the 6-year data collection period. We used a mail survey to gauge patients' opinions of the usefulness of the consultations (objective 4).
Setting The study was conducted at the Hearthstone, a UW-affiliated CCRe. At the time of the study, the CCRC was home to the residents of 227 independent-living apartments (15 of which were converted to assisted-living apartments before the \!nd of the 6-year data collection period) and a 51-bed nursing home. The CCRC employs nurses who provide "home health"-type services to apartment residents upon their request, but these patients independently seek their own medical and pharmaceutical care, and they manage their own selection and use of health services. Medical and pharmaceutical care are therefore provided by multiple practitioners, and access is often dependent upon the individual patient's insurance plan. During the study period, UW faculty, geriatric pharmacy clerkship students, and pharmacy practitioners in geriatric specialty training were present in the CCRC for 13 to 20 hours per week during the 9-month academic year and for fewer hours in the summer quarter. Among other professional activities, faculty and students under faculty direction provided consultation to apartment residents when residents requested consultations. Patient information available to faculty and students (hereafter, both are referred to as "pharmacists") when beginning a consultation for these residents was often limited to the types of medical and drug histories generally available to community pharmacists. The UW pharmacy services provided were strictly consultative; no medications were dispensed or provided, and the UW pharmacist frequently communicated with the resident's own physician or pharmacist or a CCRC nurse. Although "in-kind" support for the collaborative program was provided to UW by the CCRC, patients were not billed specifically for the UW services.
Objectives Patients Our objectives were to identify, in a retirement home population with access to consultative clinical pharmacy services: (1) the medical conditions of patients who sought consultation; (2) the
71 0
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Study patients included all independent-living and assistedliving CCRC patients who managed their own medication regimens and who sought consultation from the UW pharmacists
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during the 6-year data collection period from July 1, 1989, through June 30, 1995. Excluded were all consultations that occurred while the patient was a nursing home patient or during a period in which an apartment resident's medication administration was being supervised by nursing staff. Patients were selfreferred, but some sought pharmacy consultation upon the recommendation of a fellow resident or a CCRC staff member. Patients were informed of the availability of consultative pharmacy services through articles in the residents' monthly newsletter, by CCRC staff, and in their conversations with pharmacists (identified by name tags and white coats) throughout the building.
Data Collection The data needed for objectives 1,2, and 3 were collected on a medication consultation form designed before UW pharmacy services were initiated at the CCRe. This form was developed for pharmacists to document the care they provided, for patient follow-up services, and to record data needed for this study. On the form, pharmacists noted the chief problem as perceived by the patient, other pharmaceutical or medical problems, lists of prescription and nonprescription medications, the pharmacist's assessment, information supplied to the patient, and the follow-up plan. To pilot-test the study methods as well as to document patient care, this form was used from January 1, 1989, through June 30, 1989. The same form was used throughout the study as the data collection instrument and to document care provided by the pharmacist. A mail survey was used for objective 4. The instrument was approved by the administrator of the CCRC, approved with a recommendation for an additional question by the CCRe's Resident Council on Health Affairs, and then pilot-tested with a resident group consisting of patients served by UW pharmacists for the first time in the 10 months following the data collection period of the study. Survey questions are included in the Results section of this article. The survey was mailed in May 1996 to all living patients who had received UW pharmacy services during the study period, with the exception of those who were nursing home patients at the time of the surveyor who were assessed by nurses or the UW pharmacists as probably not capable of remembering the value of past pharmacy services, which could have been provided as early as July 1989. Patients whom the CCRC residents' visual support group identified as possibly unable to read the survey were contacted by members of the CCRe's volunteer committee and offered assistance in filling out the survey.
Data Analysis All pharmacy consultations provided to independently living patients during the study period were included in the analysis. For patients who received multiple consultations, their age at the time mid-point during consultations was considered their age. The patient's medical conditions at each consultation included
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RESEARCH
all of those identified from the patient's complaints plus those assumed by the pharmacist from his or her analysis of the patient's medical and pharmacy history, as obtained from the patient, and from a consideration of his or her medication regimen. We assumed that prescription medications were prescribed for appropriate indications. For patients with multiple consultations, chronic medical conditions recorded at one visit were considered to be present at other visits. Medical conditions were tabulated as the total number and types of different medical conditions per patient rather than conditions per visit. Before tabulating the data, the authors characterized the reasons patients sought consultations into four major categories: primary care, drug information, medication management, and medication regimen review. The first three major categories were then further defined by subcategories of patients' requests for consultation (see Results below). Similarly, we defined four major categories for tabulating pharmacists' actions and interventions: provision of primary care, drug information, medication management, and medication regimen review. Subcategories of each of the first three types of actions or interventions were also defined (see Results below). Some patient consultations were follow-ups requested by the patient or recommended by the pharmacist at the initial visit. When the follow-up led to another consultation that included patient assessment and pharmacist action or intervention, the follow-up was considered a separate consultation. In this case, the chief reason for the consultation was tabulated in both the followup and the more specific category or subcategory. We discussed the data documenting each consultation and jointly tabulated the information according to the established categories and subcategories. For the patient survey, all of the data returned, except those from the residents who pilot-tested the instrument, were included in the analysis of patients' perceptions of the usefulness of the pharmacists' services.
Results During the study period, 121 patients-WI women and 20 men-sought pharmacists' consultations. The mean (± SD) age of these patients was 84.2 (± 6.1) years, and their ages ranged from 66.0 to 100.5 years. Patients sought and received a total of 564 consultations, with a mean of 4.7 (± 5.7) and a median of 3 consultations per patient. While the majority of patients received only 1 to 3 consultations during the study period, one patient was provided 46 consultations. As shown in Figure 1, the number of consultations per year was similar in years 1 through 5 and appeared to increase in year 6. The number of medical conditions per patient identified during anyone consultation ranged from 0 to IS. The mean number of medical problems per patient who sought consultation was 4.8 (± 3.0). The various medical conditions and the number and
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Figure 1. Number of Consultations per Study Year 200
Table 1. Patient-Reported and/or PharmacistDetected Medical Conditions in More Than 5% Patients
Patients No. (%)
Condition
151 150
Cardiovascular disease a
84 (69.4)
Gastrointestinal problems
46 (38.0)
Arth ritis/gout
43 (35.5)
Probable adverse drug reaction
37 (30.6)
Endocrine abnormalities
36 (29.8)
Eye disease
34 (28.1)
CIl
c 0
'';:;
of
problems b
27 (22.3)
co
Neurologic
::::l
Pain (nonarthritis)
25 (20.7)
(,)
0
Respiratory problems
23 (19.0)
c:i
Skin abnormalities
21 (17.4)
~
CIl
c
100
z
50
o 2
3
4
5
6
Study year
percentage of study patients with these conditions are shown in Table 1. Nearly 70% of the patients had one or more cardiovascular diseases. More than 30% of the patients were identified as having a probable ADR. Pharmacists documented a total of 828 patient-perceived "chief' problems during the 564 consultations (mean, 1.5 [± 0.6]; median, 1; range, 1 to 4). The average number of chief problems identified per consultation was greater than 1 because pharmacists were sometimes unable to distinguish the patient's one main concern from the several presented. Also, 122 of the requests were for follow-up consultations; therefore, the specific request as well as the subcategory of follow-up was tabulated (see above). As shown in Figure 2, 57.4% of the patients' chief reasons for requesting consultation were for primary care, 27.5 % were for drug information, 8.60/0 were for medication management, and 6.5 % were for medication regimen review. The numbers and percentages of requests for each subcategory of assistance are shown in Tables 2, 3, and 4. Of the requests for primary care shown in Table 2, 54.7 % were for assessment of symptoms or medical problems, 26.7% were for follow-up on previous consultations for primary care, and 8.20/0 were for recommendations for therapy. T a ble 3 shows that patients had considerable concern about potential or actual adverse effects, since more than half of the requests for drug information pertained to possible adverse effects
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Journal of the American Pharmaceutical Association
Edema
21 (17.4)
Fatigue/drowsiness/weakness
20 (16.5)
Infection
19 (15.7)
Musculoskeletal problems c
18 (14.9)
Insomnia
15 (12.4)
Cerebrovascular disease
14(11.6)
Otherd
14(11.6)
Depression
12 (9.9)
Urinary incontinence
12 (9.9)
Neoplasm
12 (9.9)
Memory deficit/confusion
11 (9.1)
Hyperlipidemia
10 (8.3)
Anxiety
10 (8.3)
Osteoporosis
9 (7.4)
Medication noncompliance
8 (6.6)
None reported or detected
8 (6.6)
Peripheral vascular disease
7 (5.8)
Falls of unknown cause
7 (5.8)
alncludes hypertension, congestive heart failure, angina, coagulopathies , cardiac surgery, or arrhythmias . blncludes myoclonus, seizures, migraine headache, dizziness, Meniere's disease, vertigo, spinal stenosis, Parkinson ' s disease, tremors, neuropathies, swallowing abnormalities, weakness, or s ensory loss . clncludes nonarthritis pain, nonosteoporosis pain , carpal tunnel syndrome, leg cramps , temporomandibular joint disorder, hip arthroplasties, polymyalgia rheumatica, temporal arteritis, bursitis, he rnias , damaged spinal discs, or fibromyalgia . dlncludes perspiration/flushing, dental problems, weight loss, alopecia , mi s cellaneous genitourinary problems (bladder spasm or symptomatic p rostati c enlargement).
or drug interactions. The requests for medication management shown in Table 4 were most often for information on drug administration or dosing or use of devices. The requests for medication regimen review were not subcategorized. Pharmacists responded to the 564 consultation requests with a total of 1,491 actions or interventions for a mean of 2.6, a median of 2, and a range of 0 to 9 actions per consultation. As shown in Figure 3, 44.8 % of the actions were to provide pharmacy primary
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Pharmacists' Consultations
Figure 2. Patients' Chief Reasons for Requesting Pharmacist Consultation
RESEARCH
Figure 3. Pharmacists' Actions in Response to Patients' Requests for Consultation Documentation only
Other
1.7% Regimen review
20.5%
Drug information
27.5%
Medication management
12.1%
care. Slightly more than 20% of the pharmacists' responses included review of the patient's entire drug regimen, 19.9% of the actions were to provide requested drug information, and 12.1 % were to assist patients with managing their medications. The other category (0.8 % of total actions) included recommendations on social issues, promise of follow-up, or other actions not described by any of the categories or subcategories. For 26 of the 564 consultations, the pharmacist documented patient information but noted no specific intervention, generally because the consultation was a status report by the patient and required no further pharmacist action. These 26 responses accounted for 1.7% of the pharmacists' actions. The specific actions the pharmacists took to help patients solve identified problems are shown in Tables 5, 6, and 7. Recommending therapy and assessing the need for the patient to see other providers (triage) were the primary care actions most frequently taken. Other frequent primary care interventions were for the pharmacist to contact other providers on the patient's behalf or to recommend a procedure (e.g. , daily monitoring of blood pressure). Some patients met with the pharmacist a day or two prior to their appointments with physicians, and the pharmacist helped them make a list of pertinent issues or questions to bring to the physician' s attention. The type of drug information most often provided related to patients' concerns about possible ADRs. Medication management consultations most often related to drug administration and dosing. Of 70 patient surveys distributed, 48 (68.6%) were returned. On a scale of 0 to 10 (0 = no value, 5 = moderate value, 10 = extremely valuable), the mean of the patients' ratings of the value of the pharmacist consultations was 8.7, the median was 9.0, and the range was 5 to 10. The pharmacist's competency was rated on
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a scale of 0 to 10 (0 = not competent, 5 = moderately competent, 10 = extremely competent). The mean of the patients' ratings of the pharmacists' competency was 9.1, the median was 9.5, and the range was 5 to 10. Forty-seven patients said they would recommend the pharmacy consulting services to other residents of the CCRC (the question was left unanswered by the other respondent). Asked what type(s) of pharmacies they patronized for obtaining prescriptions and medication counseling, patients ' answers were a community pharmacy (62.5 %), the pharmacy of a health maintenance organization (16.7%), a community pharmacy plus a mail order pharmacy (14.6%), and a mail order pharmacy, Veterans Affairs pharmacy, and community pharmacy plus a health maintenance organization pharmacy (each 20/0).
Discussion This study shows that if pharmacist-provided consultation is available, older adults will use and value this health service. Our data suggest an increase in use of services by the sixth year of the study, and the 1996 numbers indicate that this trend continued: 234 consultations were provided that year for apartment residents, an increase of 55 over the total provided the last year of the study. Because of curricular changes in 1997-1998 and the addition of a pharmacy resident at the CCRC in 1998, we did not compare patients' data for these years with data from earlier years. Care needs of older adults living in retirement communities will undoubtedly increase as growing numbers of people reach retirement age. Because the UW pharmacy consultation program in the CCRC provided consultations for nursing home and assisted-living patients as well as for the independently living patients in thi
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Table 2. Pharmacy Primary Care Requests as Chief Reasons Patients Sought Consultation Primary Care Request No. Requests
% Primary Care Requests
% Total Chief Reasons
Assess symptoms/problems
260
54.7
31.4
Follow up·
127
26.7
15.3
Recommend therapy
39
8.2
4.7
Explain diagnosis/laboratory values/procedures
18
3.8
2.2
9
1.9
1. 1
Provide dietary information Assist communication with provider(s)
8
1.7
1.0
Recommend provider or specialist
4
0.8
0.5
Assess need for provider
4
0.8
0.5
4
0.8
0.5
Help with dental problems Report status b Total
2
0.4
0.2
475
99.8
57.4
"Initiated by patient or pharmacist for previously reported problem. blnitiated by patient and unrelated to prior problem .
Table 3. Drug Information Requests as Chief Reasons Patients Sought Consultation
No. Requests
% Information Requests
% Total Chief Reasons
Adverse drug reactions/side effects
98
43.0
11.9
Drug characteristics/availability
68
29.8
8.3
Efficacy
28
12.3
3.4
Interactions
22
9 .6
2.7
Brand versus generic
7
3.1
0.8
Drug stability
3
1.3
0.4
Information Sought
Costs Total
2
.9
0.2
228
100.0
27.7
Table 4. Medication Management Requests as Chief Reasons Patients Sought Consultation
Consultation Regarding
No. Requests
% Medication Management Requests
% Total Chief Reasons
Administration issues
28
39.4
3.4
Dosing
20
28.2
2 .4
Obtaining/using devices"
14
19.7
1.7
Obtaining prescriptions
4
5.6
0 .5
Taking related medicationsb
3
4.2
0.4
Discarding/storing medications
2
2.8
0.2
71
99.9
8.6
Total
aFor example, blood glucose monitors or metered-dose inhalers. bFor example, use of potassium supplementation with furosemide.
study, the pharmacists contributed to continuity of care as patients moved from one level of care to another. Administrative recognition of the value of the pharmacy program to the CCRe was shown by the establishment in 1998 of a geriatric pharmacy residency progranljointly funded by the CeRC and UW. It is important to note that the UW consultative pharmacy services were sought and utilized by retirement home residents who were also using services provided by their physicians, pharma-
714 Journal of the American Phannaceutical Miodatlon
cists, and an excellent CeRe-provided nursing staff. The pharmacy consultations were thus provided in addition to, and in collaboration with, "customary" health services. The pharmacists quite often needed to be care coordinators and/or patient advocates because of coordination and continuity problems in our changing health care systems. Our findings show that older patients expect pharmacists to provide primary care: 57.4% of their requests for consultation
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Table 5. Pharmacists' Primary Care Actions No. Actions
% Primary Care Actions
% Total Actions
Recommend therapy
150
22.5
10.1
Assess need for provider(s)
148
22.2
9 .9
Contact provider(s) on patient's behalf
103
15.4
6.9
Action
Recommend procedure"
95
14.2
6 .4
Assess physical or mental symptoms/ problems/lab data
70
10.5
4 .7
Assist communication with provider(s)
37
5.5
2 .5
Explain diagnosis/lab tests/procedures
27
4.0
1 .8
Provide dietary advice
27
4.0
1.8
Recommend provider's name or discipline Total
11
1 .6
0 .7
668
99.5
44.8
"For example. obt ain daily blood pressure readings or t est ca lcium t ab let s for disintegration.
Table 6. Pharmacists' Actions in Response to Requests for Drug Information Type of Information Provided Adverse drug reactions/adverse effects
No. Actions
% Drug Information Actions
% Total Actions
124
41.8
8.3
Drug characteristics/availability
73
24.6
4.9
Interactions
33
11.1
2 .2 1 .8
Efficacy
27
9.1
Written descriptions
24
8.1
1 .6
Brand versus generic
7
2.4
0 .5
Drug stability
5
1 .7
0.3
Kinetics
3
Costs Total
297
1.0
0 .2
0 .3
0 .1
100. 1
19.9
Table 7. Pharmacists' Actions in Response to Requests for Advice on Medication Management
Topic
No. Actions
% Medication Management Actions
% Total Actions
Medication administration
75
41.2
5.0
Dosing
62
34. 1
4 .1
Obtaining/using devices"
18
9 .9
1.2
Medication compliance
14
7.7
0 .9
Taking related medicationsb
6
3.3
0 .4
Discarding/storing medications
4
2 .2
0 .3
Obtaining prescriptions
3
1 .6
0 .2
182
100.0
12.1
Total "For example . blood glucose monitors or metered-dose inhalers. bFor example. use of potassium supplements with furosemide .
were for primary care, whereas only 42.6% of requests were in the other three major categories, which might be grouped together as requests for assistance with avoiding drug-related problems. Notably, this high percentage of requests for primary care was in an environment of good accessibility to health care providers. Even though pharmacists are the most accessible of health care providers for the general public, their roles and responsibilities in primary care are not always recognized, even by some pharma-
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cists. Pharmacy primary care has been defined as pharmaceutical care that consists of the full range of medication-related and health-promotion services provided directly to patients by pharmacists. 23 The subcategories of pharmacy primary care shown in Tables 2 and 5 illustrate some of the actions and interventions the authors consider pharmacy primary care. Our findings show that patients will come to pharmacists for help with health and medication problems and that pharmacists can serve as the first point
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of contact for treatment or triage and referral to other health care providers. In addition to their focus on pharmacotherapeutics, current pharmacy school curricula emphasize patient assessment, communication skills, and working within health care systems. Pharmacy primary care is especially important for older patients because they are highly vulnerable to stress, frequently have multiple health problems, and often need multiple-drug regimens. The pharmacy services described here can be, and sometimes are, provided by community pharmacists. Such consultations are often time-consuming and in most instances cannot be provided without remuneration. Increased research is needed on the health care costs and savings of in-depth pharmacy consultation, particularly for older adults, who usually have multiple medical problems.
phannacists' services, including primary care, therapy evaluation, drug information, and assistance with medication management. It also shows that patients were highly satisfied with the phannaceutical services provided. Community pharmacists with training in geriatric pharmacy can provide similar in-depth phannaceutical care to community-dwelling elderly patients. Further study is needed to determine the clinical and economic outcomes of comprehensive consultative pharmacy services for elderly patients. The authors declare no conflicts of interest or financial interests in any product or service mentioned in this article, including grants, employment, stock holdings, gifts, or honoraria. An abstract of this study was presented at the 1996 annual meeting of the American Society of Consultant Pharmacists, Nashville, Tenn . Acknowledgments: The authors thank Milo Gibaldi, PhD, for his review of the manuscript and his helpful recommendations. They also thank the pharmacy students and pharmacists who participated in the data collection for this 6-year study.
Limitations We did not measure whether pharmacists' consultations led to improved clinical outcomes, nor did we measure cost outcomes. We made no attempt to predict whether the consultant services prevented hospitalization or altered admissions to the CCRC's nursing home. Since services were often performed by students and supervised by faculty, it was not possible to estimate the time needed for an experienced pharmacist to perform these services. The relative homogeneity of our patient population may limit extrapolation of our results to other populations. Our sample consisted mostly of white, middle-class, well-educated retirees from the Northwest. Because we relied on patient-supplied information for documenting medical problems, the number of medical problems may be underreported. For example, if it was not clear whether the patient was taking a calcium channel blocker for angina, hypertension, or for both conditions, the patient was documented as having only one cardiovascular disease. Still, the number of patients with cardiovascular disease was higher than would be expected from age-related prevalence data. However, because our study patients were individuals who sought phannacy consultation rather than respondents to a household survey of older adults, a higher prevalence of disease in the patients participating in our study is not that surprising. Also, patients were not routinely screened for osteoporosis, hearing loss, and renal insufficiency, so these conditions were likely underreported as well. Lastly, questions related to adherence to medication regimens were not routinely asked. When nonadherence was detected, the details were documented by the pharmacist and efforts were made to improve adherence.
Conclusion This study shows that when pharmacists' consultations are available to them, retirement home residents will seek and use
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References 1. U.S. Bureau of the Census. Statistical Abstract of the United States: 1999. 119th ed. Washington, DC: U.S. Bureau ofthe Census; 1999. 2. Stewart RB . Drug use in the elderly. In: Delafuente JC, Stewart RB, eds. Therapeutics in the Elderly. Cincinnati, Ohio: Harvey Whitney Books; 1995:174-89. 3. Fozard JL, Metter EJ, Brant LJ . Next steps in describing aging and disease in longitudinal studies. J Gerontol: Psychological Sciences Speciallssue. 1990;45(4):Pll6-27. 4. Chrischilles EA, Foley DJ, Wallace RB, et al. Use of medications by persons 65 and over; from the established populations for epidemiologic studies of the elderly. J Gerontal: Medical Sciences. 1992;47(5): M137-44. 5. Hale WE, May FE, Marks RG, Stewart RB. Drug use in an ambulatory elderly population : a five-year update . Drug Intell Clin Pharm. 1987;21 :530-5. 6. Healthy People 2000. Full Report, with Commentary. Washington, DC: U.S. Department of Health and Human Services, Public Health Service; 1991 . DHHS publication (PHS)91--50212. 7. Hutchinson TA, Flegel KM, Kramer MS, et al. Frequency, severity and risk factors for adverse drug reactions in adult out patients: a prospective study. J Chronic Dis. 1986;39:533-42.
8. Gurwitz JH, Avorn J . The ambiguous relation between aging and adverse drug reactions. Ann Intern Med. 1991;1 14:95EHl6. 9. Nolan L, O'Malley K. Prescribing for the elderly. part I: sensitivity of the elderly to adverse drug reactions. JAm Geriatr Soc. 1988;36:142-9. 10. Grymonpre RE, Mitenko PA, Sitar DS, et al. Drug-associated hospital admissions in older medical patients. JAm Geriat Soc. 1988;36: 1092-8. 11 . Tanner LA, Baum C. Spontaneous adverse reaction reporting in the elderly. Lancet. 1988;ii(8610):580. 12. Beers MH, Ouslander JG, Fingold SF, et al. Inappropriate medication prescribing in skilled-nursing facilities. Ann Intern Med. 1992;117:684-9. 13. Gupta S, Rappaport HM, Bennett LT. Inappropriate drug prescribing and related outcomes for elderly Medicaid beneficiaries residing in nursing homes. Clin Ther. 1996;18:183-96. 14. Spore DL, Mor V, Larrat P, et al. Inappropriate drug prescriptions for elderly residents of board and care facilities. Am J Public Health. 1997;87:404-9. 15. Willcox SM, Himmelstein DU, Woolhandler S. Inappropriate drug prescribing for the community-dwelling elderly. JAMA. 1994;272:292-317. 16. Aparasu RR, Fliginger SE. Inappropriate medication prescribing for the elderly by office-based physicians. Ann Pharmacother. 1997;31:823-9. 17. Stuck AE, Beers MH, Steiner A, et al. Inappropriate medication use in community-residing older persons . Arch Intern Med. 1994; 154:2195-200.
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18. Aparasu RR, Sitzman SJ. Inappropriate prescribing for elderly outpatients. Am J Health Syst Pharm. 1999;56:433-9. 19. Schmader K, Hanlon JT, Weinberger M, et al. Appropriateness of med-
27. Kimberlin Cl, Berardo DH, Pendergast JF, McKenzie lG. Community
ication prescribing in ambulatory elderly patients. J Am Geriatr Soc.
28. Bradley BR, Nichol MB, lowe BF, et al. Pharmacist interventions in res-
pharmacists' influence on drug therapy decisions for elderly patients. Annu Rev Gerontal Geriatr. 1992;12:126-49. idential care facilities. Annu Rev Gerontal Geriatr. 1992;12:150-62.
1994;42:1241-7. 20. Lipton Hl, Bero LA, Bird JA, McPhee SJ. The impact of clinical phar-
29. Norton JlW, Gibson DL. Establishing an outpatient anticoagulation
macists' consultations on physicians' geriatric drug prescribing. Med Care. 1992;30:646-58.
clinic in a community hospital. Am J Health Syst Pharm.
21. Hanlon JT, Fillenbaum GG, Schmader KE, et al. Inappropriate drug use
1996;53:1151-7. 30. Knowlton CH, Thomas OV, Williamson A, et al. Establishing communi-
Pharmacotherapy.
ty pharmacy-based anticoagulation education and monitoring programs. JAm Pharm Assoc. 1999;39:368-74.
22. Golden AG, Preston RA, Barnett SO et al. Inappropriate medication
31. Oer EH, Rubenstein LZ, Choy GS. The benefits of in-home pharmacy
among
community -dwelling
elderly.
2000;20:575-82. prescribing in homebound older adults. J Am Geriatr Soc.
1999;47:948-53. 23. Plein JB. Pharmacy's paradigm: welcoming the challenges and realizing the opportunities. Am J Pharm Educ.1992;56:283-7. 24. Lipton Hl, Byrns PJ, Soumerai SB, Chrischilles EA. Pharmacists as agents of change for rational drug therapy. Int J Technol Assess Health Care. 1995;11:485-508.
25. Hepler CD, Strand lM. Opportunities and responsibilities in pharma-
evaluation for older persons. JAm Geriatr Soc. 1997;45:211-4.
32. American Society of Consultant Pharmacists. Focus on the Future: Strategic Framework, 1999-2001 [position paper]. Alexandria, Va: ASCP.
33. Kazarian O. President's address. Consult Pharm. 2000;15:422. 34. Sloan FA, Shayne MW, Conover CJ. Continuing care retirement communities: prospects for reducing institutional long-term care. J Health Polit Policy Law. 1995;20:75-98.
ceutical care. Am J Hasp Pharm. 1990;47:533-43.
26. Jameson J, Van Noord G, Vanderwoud K. The impact of a pharmacotherapy consultation on the cost and outcome of medical therapy. J Fam Pract. 1995;41:469-72.
Proscribing the Paradox The "paper consultant" phenomenon, the training of "clinical pharmacists," the problems of "overdrugging" in nursing homes-all influenced the development of the skilled nursing facility regulations of 1974. These regulations significantly expanded pharmacist involvement in skilled nursing facilities by making this health professional "responsible to the administrative staff for developing, coordinating and supervising all pharmaceutical services." In a specific effort to solve the problem of inappropriate drug therapy, the regulations required the pharmacist to review "the drug regimen of each patient at least monthly and report any irregularities to the medical director and administrator." The responsibilities of consultant pharmacists were therefore strengthened and expanded beyond the consultative role defined by the original regulations. The new regulations not only increased the pharmacist's responsibility for all pharmaceutical services, but added a significant new drug monitoring responsibility in the form of ~ monthly drug regimen review of each patient. This latter function shifted the emphasis of pharmaceutical services in these facilldes from consultation on the manipulation and storage of drug products to a staff responsibility for monitoring the patients' response to drug therapy. Requiring greater pharmacy consultation and drug monitoring services-with emphasis on the patient-was a logical response to the significant drug therapy problems that existed in skilled and other nursing facilities. The regulations offered pharmacists an opportunity to use their clinical drug monitoring skills and improve the drug therapy of skilled nursing facility patients. Such monitoring also gave the public a greater return on the investment their tax dollars were making through the Health Manpower Act of 1968.
Kidder SW. Saving cost, quality and people: drug reviews in long-term care. Am Pharm. 1978; NS 18:346-52.
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Pharmacists' Consultations Sought by Residents of a Retirement Community Jill E. Dischler, Joy B. Plein, and Elmer M. Plein
Objectives: To identify, in a retirement home population with access to pharmacists' consultations: (1) the medical conditions of patients served, (2) the primary reasons residents (patients) sought consultations, (3) the actions taken by pharmacists to resolve patient-perceived and pharmacist-detected problems, and (4) patients' perceptions of the usefulness of pharmacists' services. Design: For objectives 1,2, and 3, analysis of pharmacy records of consultations; for objective 4, mail survey of patients. Setting: A Seattlecontinuing care retirement community (CCRC) affiliated with the University of Washington School of Pharmacy for provision of pharmacy education and services. Patients: All independent-living residents of the CCRC who sought pharmacist consultation during the 6-year study period. Interventions: Advice to patients and coordination of care. Main Outcome Measures: Patients' medical conditions; reasons patients sought consultations; pharmacists' interventions; patients' perceptions of the value of services. Results: Pharmacists provided 564 consultations to 121 patients whose mean age was 84 years. The mean number of medical problems identified per patient was 4.8. Of 828 major reasons patients sought consultation, 57.4% were categorized as requests for primary care, 27.7% for drug information, 8.6% for medication management, and 6.5% for medication regimen review. Pharmacists responded with an average of 2.6 recommendations or interventions per consultation. Of the pharmacists' responses, 44.8% were categorized as primary care, 19.9% as drug information, 20.5% as regimen review, and 12.1% as medication management. Patients perceived the consultations to be highly valuable. Conclusion: If such services are available, retirement home residents will seek in-depth consultations with pharmacists on health and medication questions and problems, and they place a high value on pharmacists' advice. These services can be provided by community pharmacists with training in geriatric pharmacy.
JAm Pharm Assoc. 2001;41:709-17.
The "graying of America" is well recognized by health care professionals, the insurance industry, and the lay public. In 1998, 12.7% of the more than 270 million Americans were at least 65 years old and 1.5% were 85 or older.l The U.S . Bureau of the Census l has predicted (middle series prediction) that by 2010, 1.9% of the nearly 298 million people living in the United States will be 85 years or older, and that by 2030, 20% of the 347 million Americans will be at least 65 and 2.4% will be 85 or older. These projections present both challenges and opportunities for Received August 18, 2000, and in revised form November 28, 2000. Accepted for publication December 12, 2000. Jill E. Dischler, PharmD, is pharmacotherapist in ambulatory care and clinical assistant professor, College of Pharmacy, University of IllinoisChicago. At the time of this study, Dr. Dischler was a doctor of pharmacy student at the University of Washington, Seattle. Joy B. Plein, RPh, PhD, is professor of pharmacy; Elmer M. Plein, RPh, PhD, was Professor Emeritus of Pharmacy, School of Pharmacy, University of Washington, Seattle, and principal investigator on this study until his death in 1994. Correspondence: Joy B. Plein, RPh, PhD, School of Pharmacy, H375 HSB, Box 357630, University of Washington, Seattle, WA 98915. Fax: 206-543-3835. E-mail: [email protected].
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health care professionals. As patients advance in age, they must usually cope with increasing numbers of chronic and concomitant medical conditions.2.3 It is not surprising, therefore, that, on average, elderly adults use more drugs2.4-7 and suffer more adverse drug reactions (ADRs) than do younger patients. 7- 11 Concerns about ADRs and inappropriate prescribing for older patients have led physicians, pharmacists, and other health care professionals to investigate the appropriateness of prescribing for this population. 12- 22 Patients, alarmed by media reports, frequently express similar concerns in their conversations with pharmacists. In the late 1960s the focus of pharmacy education and practice began to shift away from a primary emphasis on dispensing and drug accountability to provision of clinical services such as prospective medication regimen review, patient counseling, and sharing drug information with other health care professionals. 23 .24 Over the last 30 years, pharmacists have taken on additional professional responsibilities, including patient assessment, treatment planning (pharmacist-initiated and/or initiated jointly with other providers), health promotion, and disease prevention. The concept of pharmaceutical care,23.25 first detailed in the early 1990s,
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makes the pharmacist directly responsible to the patient for the quality of the care she or he provides. This shift toward emphasizing clinical responsibilities began in hospitals and long-term care facilities . More recently, studies have shown the benefits of pharmacists' consultations with patients in outpatient settings24 including a family health center,26 community pharmacies,27 residential care facilities,28 anticoagulation clinics,29.3o and the patients' own homes3l and with patients being treated both with in-hospital and follow-up care.20 Since 1974, federal regulations for Medicare reimbursement to skilled nursing facilities have required pharmacist-conducted drug regimen reviews at least monthly for each resident. With a 30-year history of leadership in the development of pharmacotherapeutic services for residents of nursing homes and other long-term care facilities, the American Society of Consultant Pharmacists launched its Senior Care Pharmacy initiative in 1999. Under this strategic plan, senior care pharmacists' responsibilities include enhancing the quality of care and the quality of life for all older adults-whether they are community-dwelling or reside in institutions- "through the provision of pharmaceutical care and the promotion of healthy aging."32.33 This comprehensive approach to pharmacy's role is not site-dependent and is compatible with the goal of providing a continuum of care. The University of Washington School of Pharmacy (UW) and the Hearthstone, a continuing care retirement community34 (CCRC) in Seattle, initiated a collaborative learning/service program in January 1989. For well over a decade, the program has been training pharmacy students and practitioners in geriatric pharmacy and providing pharmacists' consultations to CCRC residents and professional staff. Faculty and students are generally present in the CCRC 2 days per week, where they provide consultations to residents of independent-living apartments (retirement home residents), nursing home residents, and assisted-living facility residents. The retirement home residents seek and manage their own health services, and the UW pharmacy services are available to them upon their own request. At the time the UW program was initiated at the Hearthstone, the authors planned this study to answer four questions: (1) What is the extent of patient-identified and pharmacist-identified medical and drug therapy problems in the retirement home population? (2) What are the reasons (self-perceived needs) that retirement home residents might seek consultative services of a pharmacist? (3) What actions might pharmacists take to respond to these patients' problems? (4) Will patients fmd the consultations helpful? In this article we answer these questions on the basis of data collected over a 6-year period from July 1989 through June 1995.
primary health and drug therapy problems perceived by independent-living patients who sought pharmacists' consultations; (3) the actions taken by pharmacists to resolve these problems as well as those detected by pharmacists; and (4) patients' perceptions of the usefulness of the pharmacists' services.
Methods Study Design For objectives 1,2, and 3 we performed a retrospective analysis of pharmacy records of all consultations provided to independent-living patients during the 6-year data collection period. We used a mail survey to gauge patients' opinions of the usefulness of the consultations (objective 4).
Setting The study was conducted at the Hearthstone, a UW-affiliated CCRe. At the time of the study, the CCRC was home to the residents of 227 independent-living apartments (15 of which were converted to assisted-living apartments before the \!nd of the 6-year data collection period) and a 51-bed nursing home. The CCRC employs nurses who provide "home health"-type services to apartment residents upon their request, but these patients independently seek their own medical and pharmaceutical care, and they manage their own selection and use of health services. Medical and pharmaceutical care are therefore provided by multiple practitioners, and access is often dependent upon the individual patient's insurance plan. During the study period, UW faculty, geriatric pharmacy clerkship students, and pharmacy practitioners in geriatric specialty training were present in the CCRC for 13 to 20 hours per week during the 9-month academic year and for fewer hours in the summer quarter. Among other professional activities, faculty and students under faculty direction provided consultation to apartment residents when residents requested consultations. Patient information available to faculty and students (hereafter, both are referred to as "pharmacists") when beginning a consultation for these residents was often limited to the types of medical and drug histories generally available to community pharmacists. The UW pharmacy services provided were strictly consultative; no medications were dispensed or provided, and the UW pharmacist frequently communicated with the resident's own physician or pharmacist or a CCRC nurse. Although "in-kind" support for the collaborative program was provided to UW by the CCRC, patients were not billed specifically for the UW services.
Objectives Patients Our objectives were to identify, in a retirement home population with access to consultative clinical pharmacy services: (1) the medical conditions of patients who sought consultation; (2) the
71 0
Joomal or the American Pbannac:eutical Assodation
Study patients included all independent-living and assistedliving CCRC patients who managed their own medication regimens and who sought consultation from the UW pharmacists
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during the 6-year data collection period from July 1, 1989, through June 30, 1995. Excluded were all consultations that occurred while the patient was a nursing home patient or during a period in which an apartment resident's medication administration was being supervised by nursing staff. Patients were selfreferred, but some sought pharmacy consultation upon the recommendation of a fellow resident or a CCRC staff member. Patients were informed of the availability of consultative pharmacy services through articles in the residents' monthly newsletter, by CCRC staff, and in their conversations with pharmacists (identified by name tags and white coats) throughout the building.
Data Collection The data needed for objectives 1,2, and 3 were collected on a medication consultation form designed before UW pharmacy services were initiated at the CCRe. This form was developed for pharmacists to document the care they provided, for patient follow-up services, and to record data needed for this study. On the form, pharmacists noted the chief problem as perceived by the patient, other pharmaceutical or medical problems, lists of prescription and nonprescription medications, the pharmacist's assessment, information supplied to the patient, and the follow-up plan. To pilot-test the study methods as well as to document patient care, this form was used from January 1, 1989, through June 30, 1989. The same form was used throughout the study as the data collection instrument and to document care provided by the pharmacist. A mail survey was used for objective 4. The instrument was approved by the administrator of the CCRC, approved with a recommendation for an additional question by the CCRe's Resident Council on Health Affairs, and then pilot-tested with a resident group consisting of patients served by UW pharmacists for the first time in the 10 months following the data collection period of the study. Survey questions are included in the Results section of this article. The survey was mailed in May 1996 to all living patients who had received UW pharmacy services during the study period, with the exception of those who were nursing home patients at the time of the surveyor who were assessed by nurses or the UW pharmacists as probably not capable of remembering the value of past pharmacy services, which could have been provided as early as July 1989. Patients whom the CCRC residents' visual support group identified as possibly unable to read the survey were contacted by members of the CCRe's volunteer committee and offered assistance in filling out the survey.
Data Analysis All pharmacy consultations provided to independently living patients during the study period were included in the analysis. For patients who received multiple consultations, their age at the time mid-point during consultations was considered their age. The patient's medical conditions at each consultation included
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all of those identified from the patient's complaints plus those assumed by the pharmacist from his or her analysis of the patient's medical and pharmacy history, as obtained from the patient, and from a consideration of his or her medication regimen. We assumed that prescription medications were prescribed for appropriate indications. For patients with multiple consultations, chronic medical conditions recorded at one visit were considered to be present at other visits. Medical conditions were tabulated as the total number and types of different medical conditions per patient rather than conditions per visit. Before tabulating the data, the authors characterized the reasons patients sought consultations into four major categories: primary care, drug information, medication management, and medication regimen review. The first three major categories were then further defined by subcategories of patients' requests for consultation (see Results below). Similarly, we defined four major categories for tabulating pharmacists' actions and interventions: provision of primary care, drug information, medication management, and medication regimen review. Subcategories of each of the first three types of actions or interventions were also defined (see Results below). Some patient consultations were follow-ups requested by the patient or recommended by the pharmacist at the initial visit. When the follow-up led to another consultation that included patient assessment and pharmacist action or intervention, the follow-up was considered a separate consultation. In this case, the chief reason for the consultation was tabulated in both the followup and the more specific category or subcategory. We discussed the data documenting each consultation and jointly tabulated the information according to the established categories and subcategories. For the patient survey, all of the data returned, except those from the residents who pilot-tested the instrument, were included in the analysis of patients' perceptions of the usefulness of the pharmacists' services.
Results During the study period, 121 patients-WI women and 20 men-sought pharmacists' consultations. The mean (± SD) age of these patients was 84.2 (± 6.1) years, and their ages ranged from 66.0 to 100.5 years. Patients sought and received a total of 564 consultations, with a mean of 4.7 (± 5.7) and a median of 3 consultations per patient. While the majority of patients received only 1 to 3 consultations during the study period, one patient was provided 46 consultations. As shown in Figure 1, the number of consultations per year was similar in years 1 through 5 and appeared to increase in year 6. The number of medical conditions per patient identified during anyone consultation ranged from 0 to IS. The mean number of medical problems per patient who sought consultation was 4.8 (± 3.0). The various medical conditions and the number and
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Pharmacists' Consultations
Figure 1. Number of Consultations per Study Year 200
Table 1. Patient-Reported and/or PharmacistDetected Medical Conditions in More Than 5% Patients
Patients No. (%)
Condition
151 150
Cardiovascular disease a
84 (69.4)
Gastrointestinal problems
46 (38.0)
Arth ritis/gout
43 (35.5)
Probable adverse drug reaction
37 (30.6)
Endocrine abnormalities
36 (29.8)
Eye disease
34 (28.1)
CIl
c 0
'';:;
of
problems b
27 (22.3)
co
Neurologic
::::l
Pain (nonarthritis)
25 (20.7)
(,)
0
Respiratory problems
23 (19.0)
c:i
Skin abnormalities
21 (17.4)
~
CIl
c
100
z
50
o 2
3
4
5
6
Study year
percentage of study patients with these conditions are shown in Table 1. Nearly 70% of the patients had one or more cardiovascular diseases. More than 30% of the patients were identified as having a probable ADR. Pharmacists documented a total of 828 patient-perceived "chief' problems during the 564 consultations (mean, 1.5 [± 0.6]; median, 1; range, 1 to 4). The average number of chief problems identified per consultation was greater than 1 because pharmacists were sometimes unable to distinguish the patient's one main concern from the several presented. Also, 122 of the requests were for follow-up consultations; therefore, the specific request as well as the subcategory of follow-up was tabulated (see above). As shown in Figure 2, 57.4% of the patients' chief reasons for requesting consultation were for primary care, 27.5 % were for drug information, 8.60/0 were for medication management, and 6.5 % were for medication regimen review. The numbers and percentages of requests for each subcategory of assistance are shown in Tables 2, 3, and 4. Of the requests for primary care shown in Table 2, 54.7 % were for assessment of symptoms or medical problems, 26.7% were for follow-up on previous consultations for primary care, and 8.20/0 were for recommendations for therapy. T a ble 3 shows that patients had considerable concern about potential or actual adverse effects, since more than half of the requests for drug information pertained to possible adverse effects
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Journal of the American Pharmaceutical Association
Edema
21 (17.4)
Fatigue/drowsiness/weakness
20 (16.5)
Infection
19 (15.7)
Musculoskeletal problems c
18 (14.9)
Insomnia
15 (12.4)
Cerebrovascular disease
14(11.6)
Otherd
14(11.6)
Depression
12 (9.9)
Urinary incontinence
12 (9.9)
Neoplasm
12 (9.9)
Memory deficit/confusion
11 (9.1)
Hyperlipidemia
10 (8.3)
Anxiety
10 (8.3)
Osteoporosis
9 (7.4)
Medication noncompliance
8 (6.6)
None reported or detected
8 (6.6)
Peripheral vascular disease
7 (5.8)
Falls of unknown cause
7 (5.8)
alncludes hypertension, congestive heart failure, angina, coagulopathies , cardiac surgery, or arrhythmias . blncludes myoclonus, seizures, migraine headache, dizziness, Meniere's disease, vertigo, spinal stenosis, Parkinson ' s disease, tremors, neuropathies, swallowing abnormalities, weakness, or s ensory loss . clncludes nonarthritis pain, nonosteoporosis pain , carpal tunnel syndrome, leg cramps , temporomandibular joint disorder, hip arthroplasties, polymyalgia rheumatica, temporal arteritis, bursitis, he rnias , damaged spinal discs, or fibromyalgia . dlncludes perspiration/flushing, dental problems, weight loss, alopecia , mi s cellaneous genitourinary problems (bladder spasm or symptomatic p rostati c enlargement).
or drug interactions. The requests for medication management shown in Table 4 were most often for information on drug administration or dosing or use of devices. The requests for medication regimen review were not subcategorized. Pharmacists responded to the 564 consultation requests with a total of 1,491 actions or interventions for a mean of 2.6, a median of 2, and a range of 0 to 9 actions per consultation. As shown in Figure 3, 44.8 % of the actions were to provide pharmacy primary
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Figure 2. Patients' Chief Reasons for Requesting Pharmacist Consultation
RESEARCH
Figure 3. Pharmacists' Actions in Response to Patients' Requests for Consultation Documentation only
Other
1.7% Regimen review
20.5%
Drug information
27.5%
Medication management
12.1%
care. Slightly more than 20% of the pharmacists' responses included review of the patient's entire drug regimen, 19.9% of the actions were to provide requested drug information, and 12.1 % were to assist patients with managing their medications. The other category (0.8 % of total actions) included recommendations on social issues, promise of follow-up, or other actions not described by any of the categories or subcategories. For 26 of the 564 consultations, the pharmacist documented patient information but noted no specific intervention, generally because the consultation was a status report by the patient and required no further pharmacist action. These 26 responses accounted for 1.7% of the pharmacists' actions. The specific actions the pharmacists took to help patients solve identified problems are shown in Tables 5, 6, and 7. Recommending therapy and assessing the need for the patient to see other providers (triage) were the primary care actions most frequently taken. Other frequent primary care interventions were for the pharmacist to contact other providers on the patient's behalf or to recommend a procedure (e.g. , daily monitoring of blood pressure). Some patients met with the pharmacist a day or two prior to their appointments with physicians, and the pharmacist helped them make a list of pertinent issues or questions to bring to the physician' s attention. The type of drug information most often provided related to patients' concerns about possible ADRs. Medication management consultations most often related to drug administration and dosing. Of 70 patient surveys distributed, 48 (68.6%) were returned. On a scale of 0 to 10 (0 = no value, 5 = moderate value, 10 = extremely valuable), the mean of the patients' ratings of the value of the pharmacist consultations was 8.7, the median was 9.0, and the range was 5 to 10. The pharmacist's competency was rated on
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a scale of 0 to 10 (0 = not competent, 5 = moderately competent, 10 = extremely competent). The mean of the patients' ratings of the pharmacists' competency was 9.1, the median was 9.5, and the range was 5 to 10. Forty-seven patients said they would recommend the pharmacy consulting services to other residents of the CCRC (the question was left unanswered by the other respondent). Asked what type(s) of pharmacies they patronized for obtaining prescriptions and medication counseling, patients ' answers were a community pharmacy (62.5 %), the pharmacy of a health maintenance organization (16.7%), a community pharmacy plus a mail order pharmacy (14.6%), and a mail order pharmacy, Veterans Affairs pharmacy, and community pharmacy plus a health maintenance organization pharmacy (each 20/0).
Discussion This study shows that if pharmacist-provided consultation is available, older adults will use and value this health service. Our data suggest an increase in use of services by the sixth year of the study, and the 1996 numbers indicate that this trend continued: 234 consultations were provided that year for apartment residents, an increase of 55 over the total provided the last year of the study. Because of curricular changes in 1997-1998 and the addition of a pharmacy resident at the CCRC in 1998, we did not compare patients' data for these years with data from earlier years. Care needs of older adults living in retirement communities will undoubtedly increase as growing numbers of people reach retirement age. Because the UW pharmacy consultation program in the CCRC provided consultations for nursing home and assisted-living patients as well as for the independently living patients in thi
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Table 2. Pharmacy Primary Care Requests as Chief Reasons Patients Sought Consultation Primary Care Request No. Requests
% Primary Care Requests
% Total Chief Reasons
Assess symptoms/problems
260
54.7
31.4
Follow up·
127
26.7
15.3
Recommend therapy
39
8.2
4.7
Explain diagnosis/laboratory values/procedures
18
3.8
2.2
9
1.9
1. 1
Provide dietary information Assist communication with provider(s)
8
1.7
1.0
Recommend provider or specialist
4
0.8
0.5
Assess need for provider
4
0.8
0.5
4
0.8
0.5
Help with dental problems Report status b Total
2
0.4
0.2
475
99.8
57.4
"Initiated by patient or pharmacist for previously reported problem. blnitiated by patient and unrelated to prior problem .
Table 3. Drug Information Requests as Chief Reasons Patients Sought Consultation
No. Requests
% Information Requests
% Total Chief Reasons
Adverse drug reactions/side effects
98
43.0
11.9
Drug characteristics/availability
68
29.8
8.3
Efficacy
28
12.3
3.4
Interactions
22
9 .6
2.7
Brand versus generic
7
3.1
0.8
Drug stability
3
1.3
0.4
Information Sought
Costs Total
2
.9
0.2
228
100.0
27.7
Table 4. Medication Management Requests as Chief Reasons Patients Sought Consultation
Consultation Regarding
No. Requests
% Medication Management Requests
% Total Chief Reasons
Administration issues
28
39.4
3.4
Dosing
20
28.2
2 .4
Obtaining/using devices"
14
19.7
1.7
Obtaining prescriptions
4
5.6
0 .5
Taking related medicationsb
3
4.2
0.4
Discarding/storing medications
2
2.8
0.2
71
99.9
8.6
Total
aFor example, blood glucose monitors or metered-dose inhalers. bFor example, use of potassium supplementation with furosemide.
study, the pharmacists contributed to continuity of care as patients moved from one level of care to another. Administrative recognition of the value of the pharmacy program to the CCRe was shown by the establishment in 1998 of a geriatric pharmacy residency progranljointly funded by the CeRC and UW. It is important to note that the UW consultative pharmacy services were sought and utilized by retirement home residents who were also using services provided by their physicians, pharma-
714 Journal of the American Phannaceutical Miodatlon
cists, and an excellent CeRe-provided nursing staff. The pharmacy consultations were thus provided in addition to, and in collaboration with, "customary" health services. The pharmacists quite often needed to be care coordinators and/or patient advocates because of coordination and continuity problems in our changing health care systems. Our findings show that older patients expect pharmacists to provide primary care: 57.4% of their requests for consultation
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Table 5. Pharmacists' Primary Care Actions No. Actions
% Primary Care Actions
% Total Actions
Recommend therapy
150
22.5
10.1
Assess need for provider(s)
148
22.2
9 .9
Contact provider(s) on patient's behalf
103
15.4
6.9
Action
Recommend procedure"
95
14.2
6 .4
Assess physical or mental symptoms/ problems/lab data
70
10.5
4 .7
Assist communication with provider(s)
37
5.5
2 .5
Explain diagnosis/lab tests/procedures
27
4.0
1 .8
Provide dietary advice
27
4.0
1.8
Recommend provider's name or discipline Total
11
1 .6
0 .7
668
99.5
44.8
"For example. obt ain daily blood pressure readings or t est ca lcium t ab let s for disintegration.
Table 6. Pharmacists' Actions in Response to Requests for Drug Information Type of Information Provided Adverse drug reactions/adverse effects
No. Actions
% Drug Information Actions
% Total Actions
124
41.8
8.3
Drug characteristics/availability
73
24.6
4.9
Interactions
33
11.1
2 .2 1 .8
Efficacy
27
9.1
Written descriptions
24
8.1
1 .6
Brand versus generic
7
2.4
0 .5
Drug stability
5
1 .7
0.3
Kinetics
3
Costs Total
297
1.0
0 .2
0 .3
0 .1
100. 1
19.9
Table 7. Pharmacists' Actions in Response to Requests for Advice on Medication Management
Topic
No. Actions
% Medication Management Actions
% Total Actions
Medication administration
75
41.2
5.0
Dosing
62
34. 1
4 .1
Obtaining/using devices"
18
9 .9
1.2
Medication compliance
14
7.7
0 .9
Taking related medicationsb
6
3.3
0 .4
Discarding/storing medications
4
2 .2
0 .3
Obtaining prescriptions
3
1 .6
0 .2
182
100.0
12.1
Total "For example . blood glucose monitors or metered-dose inhalers. bFor example. use of potassium supplements with furosemide .
were for primary care, whereas only 42.6% of requests were in the other three major categories, which might be grouped together as requests for assistance with avoiding drug-related problems. Notably, this high percentage of requests for primary care was in an environment of good accessibility to health care providers. Even though pharmacists are the most accessible of health care providers for the general public, their roles and responsibilities in primary care are not always recognized, even by some pharma-
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cists. Pharmacy primary care has been defined as pharmaceutical care that consists of the full range of medication-related and health-promotion services provided directly to patients by pharmacists. 23 The subcategories of pharmacy primary care shown in Tables 2 and 5 illustrate some of the actions and interventions the authors consider pharmacy primary care. Our findings show that patients will come to pharmacists for help with health and medication problems and that pharmacists can serve as the first point
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of contact for treatment or triage and referral to other health care providers. In addition to their focus on pharmacotherapeutics, current pharmacy school curricula emphasize patient assessment, communication skills, and working within health care systems. Pharmacy primary care is especially important for older patients because they are highly vulnerable to stress, frequently have multiple health problems, and often need multiple-drug regimens. The pharmacy services described here can be, and sometimes are, provided by community pharmacists. Such consultations are often time-consuming and in most instances cannot be provided without remuneration. Increased research is needed on the health care costs and savings of in-depth pharmacy consultation, particularly for older adults, who usually have multiple medical problems.
phannacists' services, including primary care, therapy evaluation, drug information, and assistance with medication management. It also shows that patients were highly satisfied with the phannaceutical services provided. Community pharmacists with training in geriatric pharmacy can provide similar in-depth phannaceutical care to community-dwelling elderly patients. Further study is needed to determine the clinical and economic outcomes of comprehensive consultative pharmacy services for elderly patients. The authors declare no conflicts of interest or financial interests in any product or service mentioned in this article, including grants, employment, stock holdings, gifts, or honoraria. An abstract of this study was presented at the 1996 annual meeting of the American Society of Consultant Pharmacists, Nashville, Tenn . Acknowledgments: The authors thank Milo Gibaldi, PhD, for his review of the manuscript and his helpful recommendations. They also thank the pharmacy students and pharmacists who participated in the data collection for this 6-year study.
Limitations We did not measure whether pharmacists' consultations led to improved clinical outcomes, nor did we measure cost outcomes. We made no attempt to predict whether the consultant services prevented hospitalization or altered admissions to the CCRC's nursing home. Since services were often performed by students and supervised by faculty, it was not possible to estimate the time needed for an experienced pharmacist to perform these services. The relative homogeneity of our patient population may limit extrapolation of our results to other populations. Our sample consisted mostly of white, middle-class, well-educated retirees from the Northwest. Because we relied on patient-supplied information for documenting medical problems, the number of medical problems may be underreported. For example, if it was not clear whether the patient was taking a calcium channel blocker for angina, hypertension, or for both conditions, the patient was documented as having only one cardiovascular disease. Still, the number of patients with cardiovascular disease was higher than would be expected from age-related prevalence data. However, because our study patients were individuals who sought phannacy consultation rather than respondents to a household survey of older adults, a higher prevalence of disease in the patients participating in our study is not that surprising. Also, patients were not routinely screened for osteoporosis, hearing loss, and renal insufficiency, so these conditions were likely underreported as well. Lastly, questions related to adherence to medication regimens were not routinely asked. When nonadherence was detected, the details were documented by the pharmacist and efforts were made to improve adherence.
Conclusion This study shows that when pharmacists' consultations are available to them, retirement home residents will seek and use
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18. Aparasu RR, Sitzman SJ. Inappropriate prescribing for elderly outpatients. Am J Health Syst Pharm. 1999;56:433-9. 19. Schmader K, Hanlon JT, Weinberger M, et al. Appropriateness of med-
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Proscribing the Paradox The "paper consultant" phenomenon, the training of "clinical pharmacists," the problems of "overdrugging" in nursing homes-all influenced the development of the skilled nursing facility regulations of 1974. These regulations significantly expanded pharmacist involvement in skilled nursing facilities by making this health professional "responsible to the administrative staff for developing, coordinating and supervising all pharmaceutical services." In a specific effort to solve the problem of inappropriate drug therapy, the regulations required the pharmacist to review "the drug regimen of each patient at least monthly and report any irregularities to the medical director and administrator." The responsibilities of consultant pharmacists were therefore strengthened and expanded beyond the consultative role defined by the original regulations. The new regulations not only increased the pharmacist's responsibility for all pharmaceutical services, but added a significant new drug monitoring responsibility in the form of ~ monthly drug regimen review of each patient. This latter function shifted the emphasis of pharmaceutical services in these facilldes from consultation on the manipulation and storage of drug products to a staff responsibility for monitoring the patients' response to drug therapy. Requiring greater pharmacy consultation and drug monitoring services-with emphasis on the patient-was a logical response to the significant drug therapy problems that existed in skilled and other nursing facilities. The regulations offered pharmacists an opportunity to use their clinical drug monitoring skills and improve the drug therapy of skilled nursing facility patients. Such monitoring also gave the public a greater return on the investment their tax dollars were making through the Health Manpower Act of 1968.
Kidder SW. Saving cost, quality and people: drug reviews in long-term care. Am Pharm. 1978; NS 18:346-52.
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