- Email: [email protected]
Role of student pharmacists in the identification and prevention of medication-related problems
Research Notes
Role of student pharmacists in the identification and prevention of medicationrelated problems Dalia Abdelhalim, Brice Labruzzo Mohundro, and Jeffery D. Evans
Abstract Objectives: To measure the total rate of attending physician, medical resident, and medical student acceptance of interventions recommended by third-year student pharmacists supervised by a licensed pharmacist and to determine the type of health care provider group that accepted the most interventions, type of interventions provided, and number of patients counseled on medication use. Methods: This prospective unblinded pilot study followed single interventions documented by nine third-year student pharmacists enrolled at the University of Louisiana at Monroe College of Pharmacy. Success rates of suggested interventions made to family medicine attending physicians, pharmacists, medical residents, and medical students in three Louisiana outpatient clinics were documented. Student pharmacists performed medication histories, identified potential medicationrelated problems, discussed interventions with health care providers, and counseled patients on medication use. Outcomes assessed were intervention type and number, intervention acceptance rate, and number of patients counseled. Results: Student pharmacists communicated with attending physicians, medical residents, and/or medical students regarding 32 patients. A total of 48 interventions were documented. Of these interventions, 34 were potential medicationrelated problems, 8 were pharmacotherapeutic recommendations for a new problem, 4 were responses to a health care provider’s drug information requests, and 2 were referrals to a diabetes education class. The acceptance rate of student pharmacists’ recommendations was 86%. Attending physicians accepted 93.8% of recommended interventions, medical residents 70%, and medical students 87.5%, Student pharmacists counseled 29 patients on medication use. Conclusion: Student pharmacists were able to recommend new drug regimens and discuss changes in therapy with health care providers. Attending physicians, medical residents, and medical students accepted the majority of students’ recommendations. Third-year student pharmacists have the potential to serve an important role in the identification and prevention of medication-related problems by suggesting interventions to health care providers. Keywords: Pharmacotherapy, medication-related problems, interventions, student pharmacists. J Am Pharm Assoc. 2011;51:627–630. doi: 10.1331/JAPhA.2011.09101 Journal of the American Pharmacists Association
A
ccording to the Centers for Medicare & Medicaid Services (CMS), prescription drug expenditure is expected to increase through the year 2017.1 This estimate combined with the increasing age of the U.S. population means that a greater percentage of the population will be taking prescription medications.1 In addition, many disease guidelines suggest the earlier use of medications, resulting in a greater number of younger patients using prescription medications.1 These factors may contribute to a greater incidence of medication-related problems, including adverse drug reactions, drug duplications or other improper drug selections, subtherapeutic doses, nonadherence, and overdoses.2 Pharmacists are in an excellent position to help combat the potential risk of increased medication-related problems. Medication use counseling and accurate medication history documentation are two ways in which pharmacists can help identify potential medication-related problems, decrease adverse drug events, and increase patient saftey.3–5 Pharmacists in family medicine clinics have the opportunity to spend a greater amount of time with individual patients discussing medication use compared with other health care providers.5 Medication histories aid in identifying the aforementioned medicationrelated problems and can uncover other valuable information (e.g., drug allergies, interactions, nonprescription medication use).3,4 With an aging population and continual increase in polypharmacy, pharmacists and student pharmacists can play an
Received July 8, 2009, and in revised form October 20, 2010. Accepted for publication October 22, 2010. Dalia Abdelhalim, PharmD, was a student pharmacist, College of Pharmacy, University of Louisiana at Monroe, at the time this study was conducted; she is currently Clinical Pharmacist, Medication Therapy Management Clinical Pharmacist Consulting Service, Alexandria, LA. Brice Labruzzo Mohundro, PharmD, is Assistant Professor; and Jeffery D. Evans, PharmD, is Associate Professor, College of Pharmacy, University of Louisiana at Monroe. Correspondence: Brice Labruzzo Mohundro, PharmD, College of Pharmacy, University of Louisiana at Monroe, 3849 North Blvd., Baton Rouge, LA 70806. Fax: 225-219-9813. E-mail: [email protected] Disclosure: The authors declare no conflicts of interest or financial interests in any product or service mentioned in this article, including grants, employment, gifts, stock holdings, or honoraria. Acknowledgments: To student pharmacists Kimberly Benoit, Cory Collins, Stanley Hazelton, Joseph Gary LeBlanc, Justin Lui, Chase Snyder, and Celeste Yu for participating, to Drs. Emily Evans and Ann Wicker for service as preceptors, and to the Baton Rouge General Family Health Center and Louisiana State University Health Sciences Center–Shreveport for use their clinics. Funding: American Pharmacists Association Academy of Student Pharmacists Project CHANCE grant. Previous presentation: American Pharmacists Association Annual Meeting & Exposition, San Antonio, TX, April 3–6, 2009.
www. japh a. or g
S e p /O c t 2011 • 51:5 •
JAPhA • 627
Research Notes
integral role in identifying and preventing medication-related problems. To our knowledge, no literature has reported student pharmacists in their third professional year performing medication therapy management. Therefore, the current work evaluated the ability of third-year student pharmacists to make recommendations to attending physicians, medical residents, and students regarding medication-related problems.
Objectives The primary objective of this prospective pilot study was to describe the acceptance rate of attending physicians, medical residents, and medical students regarding interventions recommended by third-year student pharmacists supervised by a licensed pharmacist. Secondary objectives were to describe the type of health care provider group that accepted the most interventions, the type of interventions provided by student pharmacists, and the number of patients counseled on medication use by student pharmacists.
Methods Nine third-year student pharmacists at the University of Louisiana at Monroe College of Pharmacy (ULM-COP) participated in the study. ULM-COP faculty provided a medication therapy management orientation before students were able to interact with patients. This required orientation included proper techniques for conducting a medication history and how to screen for medication-related problems. Students also were instructed on how to document interventions using an intervention form (Appendix 1 in the electronic version of this article, available online at www.japha.org). The intervention form also served as the data collection form. To comply with the Health Insurance Portability and Accountability Act (HIPAA), student pharmacists did not record protected health information on the intervention forms. HIPAA training is required by ULM-COP for all students; however, students involved in this study also completed HIPAA training for the clinic located in southern Louisiana. The study was approved by the institutional review boards of the University of Louisiana, Louisiana State University Health Science Center–Shreveport, and Baton Rouge General Medical Center. To participate, student pharmacists must have been enrolled in the third professional year of pharmacy curriculum at ULM-COP during summer 2008. Because funding for this study was acquired through the American Pharmacists Association Academy of Student Pharmacists (APhA–ASP) Project CHANCE program, students were required to be members of APhA–ASP. Participating pharmacists were ULM-COP faculty with clinical responsibilities to the family medicine clinics. As part of multidisciplinary teams, pharmacists’ clinical responsibilities included addressing drug information requests and serving as consultants for patients with complex drug regimens. The study involved patients, attending physicians, medical residents, and medical students located at two clinics in northern Louisiana that were associated with the family medicine department of the Louisiana State University Health Sciences Center–Shreveport. One clinic was a limb clinic for pa628 • JAPhA • 51 : 5 • S e p / O c t 2011
www.j aph a. or g
tients with diabetes and the other a primary care clinic run by medical students. In the southern region of the state, the Baton Rouge General Family Health Center, a family medicine residency program clinic, was used. Student pharmacists evaluated patients during a 6-month period. In the patients’ examination room, student pharmacists performed medication histories using open-ended questions. Students were able to practice interviewing skills with the preceptors at the respective sites if the students or faculty felt practice was necessary. Medication histories were obtained by student pharmacists in most cases; however, in several situations, medication histories were not performed because immediate answers were sought by pharmacists, attending physicians, medical residents, and/or medical students. Data were collected via a medication history form (online Appendix 2). Patients’ medical records and medications brought from home were used to assist with medication histories. After completing the medication history, student pharmacists reviewed the data to identify medication-related problems. Interventions were identified by student pharmacists either during medical record reviews before patients’ appointments or after medication histories were obtained from patients. Potential interventions were discussed with the faculty members first and then directly (face-to-face) communicated to attending physicians, medical residents, and/or medical students. Interventions were categorized as follows: need for additional therapy, change of drug for economic reasons, drug–disease interactions, duplicate therapy, nonadherence, subtherapeutic or supratherapeutic dose, or untreated indications. Acceptance or rejection of a recommendation by attending physicians, medical residents, or medical students was documented on the intervention form (online Appendix 1). Medication counseling was provided when patients were prescribed a new medication, improper medication use was identified, questions were asked by patients, and/or a request was made by attending physicians, medical residents, and/or medical students. Students reviewed counseling points with faculty before discussing with patients. Student pharmacists used various counseling tools to help patients better understand and use their medications. Medication administration forms prepared by student pharmacists were given to patients to assist with the retention of counseling points. Medication administration form included drug name, dose, color, directions, and indication. Handouts were provided to supplement the discussed information. Results are presented using descriptive statistics. Data are stratified by the following categories: additional therapy needed, change drug due to economics, drug–disease interaction, duplication of therapy, nonadherence, subtherapeutic dose, supratherapeutic dose, and untreated indications.
Results A total of 32 patients were seen by the nine student pharmacists during the 6-month study period (June through December 2008). Acceptance rates were high for all groups, with 86% of recommendations being accepted. Medical students most freJournal of the American Pharmacists Association
Research Notes Figure 1.pdf
1
8/23/11
9:40 AM
Table 1. Potential medication-related problems identified by third-year student pharmacists
20
C
M
Y
CM
MY
CY
CMY
K
No. of interventions
18 16 14 12 10
Yes
8
No
6
Not documented
4 2 0 Attending
Residents Health care provider
Medical students
Figure 1. Number of interventions recommended by third-year student pharmacists and whether they were accepted by health care providers Figure 2.pdf
1
8/23/11
9:41 AM
Additional therapy needed 23%
26%
C
Change drug due to economics
M
Drug-disease interaction
Y
CM
6%
MY
Duplication of therapy
CY
CMY
9%
3%
K
12%
9% 12%
Nonadherence Subtherapeutic dose Supratherapeutic dose Untreated indications
Figure 2. Potential medication-related problems identified by thirdyear student pharmacists quently accepted the interventions identified by student pharmacists (93.8%), followed by attending physicians (87.5%) and medical residents (70%) (Figure 1). Student pharmacists documented 48 interventions. Of these, 34 were potential medication-related problems (Figure 2), 8 were pharmacotherapeutic recommendations for a new problem, 4 were responses to health care provider drug information requests, and 2 were referrals to a diabetes education class. One-half of the identified medication-related problems resulted in a recommendation to begin a new drug in order to optimize medication regimens. Third-year student pharmacists were able to identify duplication of therapy with nonsteroidal anti-inflammatory drugs and selective serotonin reuptake inhibitors, as well as systemic antifungal agents, in a pediatric patient (Table 1). Student pharmacists also suggested changing drugs because of safety concerns. A total of 29 patients were counseled on medication use.
Discussion Few studies have evaluated the value of third-year student pharmacists as part of a multidisciplinary health care team. In the current study, recommendations provided by student pharJournal of the American Pharmacists Association
17-month-old child receiving griseofulvin and itraconzaole to treat onchomycosis Patient prescribed sertraline and fluoxetine by two different physicians Untreated indications, including tobacco abuse, asthma, and gastroesophageal reflux disease Multiple patients with diabetes not taking aspirin for primary prevention of cardiovascular events Additional therapy suggested for several patients with uncontrolled hypertension, uncontrolled pain control, or uncontrolled lipid disorders macists had a high rate of acceptance by attending physicians, medical residents, and students in family medicine clinics where faculty are active members of multidisciplinary services. Reports have indicated that face-to-face communication with physicians can result in higher acceptance rates of pharmacists’ recommendations compared with written recommendations.6 Student pharmacists communicating directly with physicians, medical residents, and students may have contributed to the high acceptance rate demonstrated in this study. Student pharmacists recorded patients’ medication histories, counseled patients on medication use, evaluated patients’ medication therapies, identified potential medication-related problems, and communicated with health care providers regarding modification of patients’ medication therapies. Results showed a potential clinically advantageous role of student pharmacists in family medicine clinics. Student pharmacists were able to identify potential medication-related problems and discuss recommendations pertaining to drug therapy with health care providers at family medicine clinics in Louisiana. Medical students were more likely to accept recommendations made by student pharmacists than by attending physicians and medical residents, suggesting the importance of physician–pharmacist interactions during early stages of medical education. A white paper on interprofessional education published by the American College of Clinical Pharmacy (ACCP) reinforces this observation. The ACCP white paper describes how the lack of interprofessional education (both didactic and experiential) has been associated with a decrease in the quality of patient care.7
Limitations This pilot study had several limitations. The first limitation occurred during orientation for the study, at which point clear guidelines for patient inclusion were not provided. The students were told to enroll patients; however, they were not instructed regarding whether patients should be on a minimum number of medications or have a minimum number of comorbid conditions. In addition, the orientation was provided via a distance learning conference. If faculty were present in the same location as students, the orientation may have been more effective. Also, as a result of unforeseen circumstances, students were www. japh a. or g
S e p /O c t 2011 • 51:5 •
JAPhA • 629
Research Notes
not able to participate at the family medicine clinic located in Monroe, LA, where the main campus of ULM-COP is located. Because of this, student pharmacists were required to travel to clinics located 1 to 3.5 hours away from the college’s main campus. Upon agreeing to participate in the study, student pharmacists were not aware they would be required to travel to clinics located outside of Monroe, as participation in the other clinics was optional. This greatly decreased the amount of time students spent in the clinics and possibly the number of interventions that could have been identified, as there was less time for the students to develop a relationship with other health care providers. Also, months of time may have lapsed between visits because of travel limitations, and student pharmacists may have had more valuable clinical experiences if the visits occurred on a more regularly scheduled basis. Future efforts will seek to allow student participation at a clinic near ULM-COP. Another limitation of the study is that all participants were members of APhA–ASP; therefore, these students may have been more motivated than others. Last, faculty acceptance rate of student recommendations and the effectiveness of student medication history taking (e.g., whether all medication-related problems were identified) were not evaluated. This information would have been beneficial to determine how useful the student pharmacists were in the family medicine clinics. We identified several refinements that could be addressed in future studies. The categories of interventions on the intervention form could be changed to align with the medicationrelated problems discussed (e.g., untreated indication, drug interaction, improper drug selection, over- or underdosage, medication without indication, failure to receive drug). During the student orientation, the type of patients to screen (e.g., those on more than five medications) should be discussed. In addition to the data collected for the study, evaluating the effects on patient outcomes (e.g., blood pressure, diabetes control) would be valuable. Finally, data analyzing the effectiveness of the students at interpreting potential drug–drug interactions should be collected to determine whether third-year (or earlier) stu-
630 • JAPhA • 51 : 5 • S e p / O c t 2011
www.j aph a. or g
dent pharmacists are capable of functioning at the level needed to complete a study (and thus real clinical experiences.)
Conclusion Third-year student pharmacists were able to recommend new drug regimens and discuss changes in therapy with physicians, medical residents, and students. Attending physicians, medical residents, and medical students worked with student pharmacists in a multidisciplinary team and accepted recommendations in assessing and correcting medication-related problems. Student pharmacists have an important role in the identification and prevention of medication-related problems by suggesting interventions to attending physicians, medical residents, and medical students. References 1. Centers for Medicare & Medicaid Services. National health expenditure projections 2007-2017. Accessed at www.nipcweb. com/NHE_Projections.pdf, July 15, 2011. 2. Cipolle RJ, Strand LM, Morley PC. Pharmaceutical care practice: the clinician’s guide. Accessed at www.accesspharmacy.com/ content.aspx?aID=2493000, July 26, 2010. 3. Akwagyriam I, Goodyer LI, Harding L, et al. Drug history taking and the identification of drug related problems in an accident and emergency department. J Accid Emerg Med. 1996;13:166–8. 4. Nester TM, Hale LS. Effectiveness of a pharmacist-acquired medication history in promoting patient safety. Am J Health Syst Pharm. 2002;59:2221–5. 5. Schnipper JL, Kirwin JL, Cotugno MC, et al. Role of pharmacist counseling in preventing adverse drug events after hospitalization. Arch Intern Med. 2006;166:565–71. 6. Denneboom W, Dautzenberg MG, Grol R, De Smet PA. Treatment reviews of older people on polypharmacy in primary care: cluster controlled trial comparing two approaches. Br J Gen Pract. 2007;723–31. 7. Page RL 2nd, Hume AL, Trujillo JM, et al. Interprofessional education: principles and application: a framework for clinical pharmacy. Pharmacotherapy. 2009;29:145–64e.
Journal of the American Pharmacists Association
Role of student pharmacists in the identification and prevention of medicationrelated problems Dalia Abdelhalim, Brice Labruzzo Mohundro, and Jeffery D. Evans
Abstract Objectives: To measure the total rate of attending physician, medical resident, and medical student acceptance of interventions recommended by third-year student pharmacists supervised by a licensed pharmacist and to determine the type of health care provider group that accepted the most interventions, type of interventions provided, and number of patients counseled on medication use. Methods: This prospective unblinded pilot study followed single interventions documented by nine third-year student pharmacists enrolled at the University of Louisiana at Monroe College of Pharmacy. Success rates of suggested interventions made to family medicine attending physicians, pharmacists, medical residents, and medical students in three Louisiana outpatient clinics were documented. Student pharmacists performed medication histories, identified potential medicationrelated problems, discussed interventions with health care providers, and counseled patients on medication use. Outcomes assessed were intervention type and number, intervention acceptance rate, and number of patients counseled. Results: Student pharmacists communicated with attending physicians, medical residents, and/or medical students regarding 32 patients. A total of 48 interventions were documented. Of these interventions, 34 were potential medicationrelated problems, 8 were pharmacotherapeutic recommendations for a new problem, 4 were responses to a health care provider’s drug information requests, and 2 were referrals to a diabetes education class. The acceptance rate of student pharmacists’ recommendations was 86%. Attending physicians accepted 93.8% of recommended interventions, medical residents 70%, and medical students 87.5%, Student pharmacists counseled 29 patients on medication use. Conclusion: Student pharmacists were able to recommend new drug regimens and discuss changes in therapy with health care providers. Attending physicians, medical residents, and medical students accepted the majority of students’ recommendations. Third-year student pharmacists have the potential to serve an important role in the identification and prevention of medication-related problems by suggesting interventions to health care providers. Keywords: Pharmacotherapy, medication-related problems, interventions, student pharmacists. J Am Pharm Assoc. 2011;51:627–630. doi: 10.1331/JAPhA.2011.09101 Journal of the American Pharmacists Association
A
ccording to the Centers for Medicare & Medicaid Services (CMS), prescription drug expenditure is expected to increase through the year 2017.1 This estimate combined with the increasing age of the U.S. population means that a greater percentage of the population will be taking prescription medications.1 In addition, many disease guidelines suggest the earlier use of medications, resulting in a greater number of younger patients using prescription medications.1 These factors may contribute to a greater incidence of medication-related problems, including adverse drug reactions, drug duplications or other improper drug selections, subtherapeutic doses, nonadherence, and overdoses.2 Pharmacists are in an excellent position to help combat the potential risk of increased medication-related problems. Medication use counseling and accurate medication history documentation are two ways in which pharmacists can help identify potential medication-related problems, decrease adverse drug events, and increase patient saftey.3–5 Pharmacists in family medicine clinics have the opportunity to spend a greater amount of time with individual patients discussing medication use compared with other health care providers.5 Medication histories aid in identifying the aforementioned medicationrelated problems and can uncover other valuable information (e.g., drug allergies, interactions, nonprescription medication use).3,4 With an aging population and continual increase in polypharmacy, pharmacists and student pharmacists can play an
Received July 8, 2009, and in revised form October 20, 2010. Accepted for publication October 22, 2010. Dalia Abdelhalim, PharmD, was a student pharmacist, College of Pharmacy, University of Louisiana at Monroe, at the time this study was conducted; she is currently Clinical Pharmacist, Medication Therapy Management Clinical Pharmacist Consulting Service, Alexandria, LA. Brice Labruzzo Mohundro, PharmD, is Assistant Professor; and Jeffery D. Evans, PharmD, is Associate Professor, College of Pharmacy, University of Louisiana at Monroe. Correspondence: Brice Labruzzo Mohundro, PharmD, College of Pharmacy, University of Louisiana at Monroe, 3849 North Blvd., Baton Rouge, LA 70806. Fax: 225-219-9813. E-mail: [email protected] Disclosure: The authors declare no conflicts of interest or financial interests in any product or service mentioned in this article, including grants, employment, gifts, stock holdings, or honoraria. Acknowledgments: To student pharmacists Kimberly Benoit, Cory Collins, Stanley Hazelton, Joseph Gary LeBlanc, Justin Lui, Chase Snyder, and Celeste Yu for participating, to Drs. Emily Evans and Ann Wicker for service as preceptors, and to the Baton Rouge General Family Health Center and Louisiana State University Health Sciences Center–Shreveport for use their clinics. Funding: American Pharmacists Association Academy of Student Pharmacists Project CHANCE grant. Previous presentation: American Pharmacists Association Annual Meeting & Exposition, San Antonio, TX, April 3–6, 2009.
www. japh a. or g
S e p /O c t 2011 • 51:5 •
JAPhA • 627
Research Notes
integral role in identifying and preventing medication-related problems. To our knowledge, no literature has reported student pharmacists in their third professional year performing medication therapy management. Therefore, the current work evaluated the ability of third-year student pharmacists to make recommendations to attending physicians, medical residents, and students regarding medication-related problems.
Objectives The primary objective of this prospective pilot study was to describe the acceptance rate of attending physicians, medical residents, and medical students regarding interventions recommended by third-year student pharmacists supervised by a licensed pharmacist. Secondary objectives were to describe the type of health care provider group that accepted the most interventions, the type of interventions provided by student pharmacists, and the number of patients counseled on medication use by student pharmacists.
Methods Nine third-year student pharmacists at the University of Louisiana at Monroe College of Pharmacy (ULM-COP) participated in the study. ULM-COP faculty provided a medication therapy management orientation before students were able to interact with patients. This required orientation included proper techniques for conducting a medication history and how to screen for medication-related problems. Students also were instructed on how to document interventions using an intervention form (Appendix 1 in the electronic version of this article, available online at www.japha.org). The intervention form also served as the data collection form. To comply with the Health Insurance Portability and Accountability Act (HIPAA), student pharmacists did not record protected health information on the intervention forms. HIPAA training is required by ULM-COP for all students; however, students involved in this study also completed HIPAA training for the clinic located in southern Louisiana. The study was approved by the institutional review boards of the University of Louisiana, Louisiana State University Health Science Center–Shreveport, and Baton Rouge General Medical Center. To participate, student pharmacists must have been enrolled in the third professional year of pharmacy curriculum at ULM-COP during summer 2008. Because funding for this study was acquired through the American Pharmacists Association Academy of Student Pharmacists (APhA–ASP) Project CHANCE program, students were required to be members of APhA–ASP. Participating pharmacists were ULM-COP faculty with clinical responsibilities to the family medicine clinics. As part of multidisciplinary teams, pharmacists’ clinical responsibilities included addressing drug information requests and serving as consultants for patients with complex drug regimens. The study involved patients, attending physicians, medical residents, and medical students located at two clinics in northern Louisiana that were associated with the family medicine department of the Louisiana State University Health Sciences Center–Shreveport. One clinic was a limb clinic for pa628 • JAPhA • 51 : 5 • S e p / O c t 2011
www.j aph a. or g
tients with diabetes and the other a primary care clinic run by medical students. In the southern region of the state, the Baton Rouge General Family Health Center, a family medicine residency program clinic, was used. Student pharmacists evaluated patients during a 6-month period. In the patients’ examination room, student pharmacists performed medication histories using open-ended questions. Students were able to practice interviewing skills with the preceptors at the respective sites if the students or faculty felt practice was necessary. Medication histories were obtained by student pharmacists in most cases; however, in several situations, medication histories were not performed because immediate answers were sought by pharmacists, attending physicians, medical residents, and/or medical students. Data were collected via a medication history form (online Appendix 2). Patients’ medical records and medications brought from home were used to assist with medication histories. After completing the medication history, student pharmacists reviewed the data to identify medication-related problems. Interventions were identified by student pharmacists either during medical record reviews before patients’ appointments or after medication histories were obtained from patients. Potential interventions were discussed with the faculty members first and then directly (face-to-face) communicated to attending physicians, medical residents, and/or medical students. Interventions were categorized as follows: need for additional therapy, change of drug for economic reasons, drug–disease interactions, duplicate therapy, nonadherence, subtherapeutic or supratherapeutic dose, or untreated indications. Acceptance or rejection of a recommendation by attending physicians, medical residents, or medical students was documented on the intervention form (online Appendix 1). Medication counseling was provided when patients were prescribed a new medication, improper medication use was identified, questions were asked by patients, and/or a request was made by attending physicians, medical residents, and/or medical students. Students reviewed counseling points with faculty before discussing with patients. Student pharmacists used various counseling tools to help patients better understand and use their medications. Medication administration forms prepared by student pharmacists were given to patients to assist with the retention of counseling points. Medication administration form included drug name, dose, color, directions, and indication. Handouts were provided to supplement the discussed information. Results are presented using descriptive statistics. Data are stratified by the following categories: additional therapy needed, change drug due to economics, drug–disease interaction, duplication of therapy, nonadherence, subtherapeutic dose, supratherapeutic dose, and untreated indications.
Results A total of 32 patients were seen by the nine student pharmacists during the 6-month study period (June through December 2008). Acceptance rates were high for all groups, with 86% of recommendations being accepted. Medical students most freJournal of the American Pharmacists Association
Research Notes Figure 1.pdf
1
8/23/11
9:40 AM
Table 1. Potential medication-related problems identified by third-year student pharmacists
20
C
M
Y
CM
MY
CY
CMY
K
No. of interventions
18 16 14 12 10
Yes
8
No
6
Not documented
4 2 0 Attending
Residents Health care provider
Medical students
Figure 1. Number of interventions recommended by third-year student pharmacists and whether they were accepted by health care providers Figure 2.pdf
1
8/23/11
9:41 AM
Additional therapy needed 23%
26%
C
Change drug due to economics
M
Drug-disease interaction
Y
CM
6%
MY
Duplication of therapy
CY
CMY
9%
3%
K
12%
9% 12%
Nonadherence Subtherapeutic dose Supratherapeutic dose Untreated indications
Figure 2. Potential medication-related problems identified by thirdyear student pharmacists quently accepted the interventions identified by student pharmacists (93.8%), followed by attending physicians (87.5%) and medical residents (70%) (Figure 1). Student pharmacists documented 48 interventions. Of these, 34 were potential medication-related problems (Figure 2), 8 were pharmacotherapeutic recommendations for a new problem, 4 were responses to health care provider drug information requests, and 2 were referrals to a diabetes education class. One-half of the identified medication-related problems resulted in a recommendation to begin a new drug in order to optimize medication regimens. Third-year student pharmacists were able to identify duplication of therapy with nonsteroidal anti-inflammatory drugs and selective serotonin reuptake inhibitors, as well as systemic antifungal agents, in a pediatric patient (Table 1). Student pharmacists also suggested changing drugs because of safety concerns. A total of 29 patients were counseled on medication use.
Discussion Few studies have evaluated the value of third-year student pharmacists as part of a multidisciplinary health care team. In the current study, recommendations provided by student pharJournal of the American Pharmacists Association
17-month-old child receiving griseofulvin and itraconzaole to treat onchomycosis Patient prescribed sertraline and fluoxetine by two different physicians Untreated indications, including tobacco abuse, asthma, and gastroesophageal reflux disease Multiple patients with diabetes not taking aspirin for primary prevention of cardiovascular events Additional therapy suggested for several patients with uncontrolled hypertension, uncontrolled pain control, or uncontrolled lipid disorders macists had a high rate of acceptance by attending physicians, medical residents, and students in family medicine clinics where faculty are active members of multidisciplinary services. Reports have indicated that face-to-face communication with physicians can result in higher acceptance rates of pharmacists’ recommendations compared with written recommendations.6 Student pharmacists communicating directly with physicians, medical residents, and students may have contributed to the high acceptance rate demonstrated in this study. Student pharmacists recorded patients’ medication histories, counseled patients on medication use, evaluated patients’ medication therapies, identified potential medication-related problems, and communicated with health care providers regarding modification of patients’ medication therapies. Results showed a potential clinically advantageous role of student pharmacists in family medicine clinics. Student pharmacists were able to identify potential medication-related problems and discuss recommendations pertaining to drug therapy with health care providers at family medicine clinics in Louisiana. Medical students were more likely to accept recommendations made by student pharmacists than by attending physicians and medical residents, suggesting the importance of physician–pharmacist interactions during early stages of medical education. A white paper on interprofessional education published by the American College of Clinical Pharmacy (ACCP) reinforces this observation. The ACCP white paper describes how the lack of interprofessional education (both didactic and experiential) has been associated with a decrease in the quality of patient care.7
Limitations This pilot study had several limitations. The first limitation occurred during orientation for the study, at which point clear guidelines for patient inclusion were not provided. The students were told to enroll patients; however, they were not instructed regarding whether patients should be on a minimum number of medications or have a minimum number of comorbid conditions. In addition, the orientation was provided via a distance learning conference. If faculty were present in the same location as students, the orientation may have been more effective. Also, as a result of unforeseen circumstances, students were www. japh a. or g
S e p /O c t 2011 • 51:5 •
JAPhA • 629
Research Notes
not able to participate at the family medicine clinic located in Monroe, LA, where the main campus of ULM-COP is located. Because of this, student pharmacists were required to travel to clinics located 1 to 3.5 hours away from the college’s main campus. Upon agreeing to participate in the study, student pharmacists were not aware they would be required to travel to clinics located outside of Monroe, as participation in the other clinics was optional. This greatly decreased the amount of time students spent in the clinics and possibly the number of interventions that could have been identified, as there was less time for the students to develop a relationship with other health care providers. Also, months of time may have lapsed between visits because of travel limitations, and student pharmacists may have had more valuable clinical experiences if the visits occurred on a more regularly scheduled basis. Future efforts will seek to allow student participation at a clinic near ULM-COP. Another limitation of the study is that all participants were members of APhA–ASP; therefore, these students may have been more motivated than others. Last, faculty acceptance rate of student recommendations and the effectiveness of student medication history taking (e.g., whether all medication-related problems were identified) were not evaluated. This information would have been beneficial to determine how useful the student pharmacists were in the family medicine clinics. We identified several refinements that could be addressed in future studies. The categories of interventions on the intervention form could be changed to align with the medicationrelated problems discussed (e.g., untreated indication, drug interaction, improper drug selection, over- or underdosage, medication without indication, failure to receive drug). During the student orientation, the type of patients to screen (e.g., those on more than five medications) should be discussed. In addition to the data collected for the study, evaluating the effects on patient outcomes (e.g., blood pressure, diabetes control) would be valuable. Finally, data analyzing the effectiveness of the students at interpreting potential drug–drug interactions should be collected to determine whether third-year (or earlier) stu-
630 • JAPhA • 51 : 5 • S e p / O c t 2011
www.j aph a. or g
dent pharmacists are capable of functioning at the level needed to complete a study (and thus real clinical experiences.)
Conclusion Third-year student pharmacists were able to recommend new drug regimens and discuss changes in therapy with physicians, medical residents, and students. Attending physicians, medical residents, and medical students worked with student pharmacists in a multidisciplinary team and accepted recommendations in assessing and correcting medication-related problems. Student pharmacists have an important role in the identification and prevention of medication-related problems by suggesting interventions to attending physicians, medical residents, and medical students. References 1. Centers for Medicare & Medicaid Services. National health expenditure projections 2007-2017. Accessed at www.nipcweb. com/NHE_Projections.pdf, July 15, 2011. 2. Cipolle RJ, Strand LM, Morley PC. Pharmaceutical care practice: the clinician’s guide. Accessed at www.accesspharmacy.com/ content.aspx?aID=2493000, July 26, 2010. 3. Akwagyriam I, Goodyer LI, Harding L, et al. Drug history taking and the identification of drug related problems in an accident and emergency department. J Accid Emerg Med. 1996;13:166–8. 4. Nester TM, Hale LS. Effectiveness of a pharmacist-acquired medication history in promoting patient safety. Am J Health Syst Pharm. 2002;59:2221–5. 5. Schnipper JL, Kirwin JL, Cotugno MC, et al. Role of pharmacist counseling in preventing adverse drug events after hospitalization. Arch Intern Med. 2006;166:565–71. 6. Denneboom W, Dautzenberg MG, Grol R, De Smet PA. Treatment reviews of older people on polypharmacy in primary care: cluster controlled trial comparing two approaches. Br J Gen Pract. 2007;723–31. 7. Page RL 2nd, Hume AL, Trujillo JM, et al. Interprofessional education: principles and application: a framework for clinical pharmacy. Pharmacotherapy. 2009;29:145–64e.
Journal of the American Pharmacists Association