Sometime the doctor is wrong

When you care Heart failure patients and Myocardial infarction patient .
Many case the doctor have take not appropriated medicines.
Common mistake
No BB and ACEI drug.

All in project

Introduction: Chronic patient care is not good enough. We can do something for chronic patient to improve quality of care.

Objective: To reduce mortality and mobility rate of chronic patient.
To increase quality of life WHO QOL score of chronic renal failureDM patient.

Patient: Intervention(n=250) and control group(n=250).

Duration: 24 month

Tactics:

1. Counseling
2. Telephone care
3. Home visit
4. Group meeting
5. Seminar
6. Volunteer support
7. Group exercises
8. Drug checking

Budget: 35000 dollars

Start 31/03/2008

The great action

Improving Quality of Care in Diabetes Through a Comprehensive Pharmacist-Based Disease Management Program

Sandra Leal, PHARMD, CDE1,2, Jon J. Glover, PHARMD2,3, Richard N. Herrier, PHARMD2 and Anthony Felix, RPH1,2

1 El Rio Health Center, Tucson, Arizona

2 University of Arizona College of Pharmacy, Tucson, Arizona

3 Pfizer Pharmaceuticals, Phoenix, Arizona

Address correspondence and reprint requests to Richard N. Herrier, PharmD, College of Pharmacy, University of Arizona, 1703 E. Mabel, Tucson, AZ 85721-0207. E-mail: herrier@pharmacy.arizona.edu

Introduction

In the U.S., a large percentage of patients with diabetes receive less than optimal care (1). The use of pharmacists, nurse practitioners, and multidisciplinary teams in a variety of settings have led to improvements in disease control in patients with diabetes and other chronic diseases (2–14). This report describes the utility of a pharmacist-run disease management program in improving the care of predominately indigent, Spanish-speaking patients with diabetes and common comorbid conditions.

Method

The study was conducted at El Rio Health Center, which is a federally qualified health center located in Tucson, Arizona. The patient population is comprised mostly of indigent, Spanish-speaking, and sometimes transient patients with primarily type 2 diabetes. The program was implemented in August 2001, using a residency-trained, bilingual PharmD as the provider for patients referred to the pharmacist-based diabetes service by staff physicians. The pharmacist served as the primary care provider for the patients’ diabetes and comorbid conditions, hypertension, and hyperlipidemia. Using medical staff–approved collaborative practice agreements, the pharmacist provided appropriate diagnostic, educational, and therapeutic management services, including prescribing medication and ordering laboratory tests. The collaborative practice agreements were based on national standards of care for diabetes, hypertension, and hyperlipidemia. The pharmacist used a customized Microsoft Access database to facilitate documentation of services and appropriate patient management.

All patients who had an initial visit, plus at least one additional visit over the following 90 days, were included in this analysis. Patients served as their own controls. Comparisons of continuous data from baseline to follow-up, such as lipid parameters, glucose, weight, BMI, blood pressure, and A1C were compared using a paired t test. Changes from baseline to follow-up in percentages or proportions, such as changes in percentage of patients at LDL cholesterol goal, use of aspirin, or patients at blood pressure goal, were compared using CIs and two-proportion testing. Significance for all statistical comparisons were set at {alpha} = 0.05.

Conclusion

The 2% drop in mean A1C is similar to that achieved in a Veterans Administration pharmacist-based program (6). In the Veterans Administration study, only 26% of patients had their A1C lowered to <8.0%>10% (8 vs. 14.9%). The percentages were also superior for patients receiving dilated eye examinations (99.5 vs. 63.3%) and foot examination (99.5 vs. 54.8%) (1).

Because of the unique population and practice setting, application of these findings to other pharmacist-managed programs may be problematic. Thirty-seven states allow pharmacists to prescribe medications. Arizona, along with several other states, require drug- or disease-specific collaborative practice agreements that have been approved by physicians participating in these programs. Pharmacist clinical privileges in this study were defined by such an agreement. The use of a bilingual pharmacist may have contributed to the service’s success through clearer communication and attention to cultural nuances that contribute to patient adherence. Also, many of the patients included in the data analysis were referred to the pharmacist because of the inability of previous care to obtain adequate disease control. This tended to provide a population that was inherently more difficult to achieve target levels of blood pressure, blood glucose, and lipids. Finally, El Rio Health Center is organizationally a staff model HMO where physicians, other professionals, and ancillary staff are employees of the delivery system. This facilitates the smooth integration of pharmacists into expanded roles and provides a patient care structure that supports the delivery of comprehensive care.

A pharmacist-managed service for the care of diabetes and frequently associated comorbid conditions was effective in significantly lowering A1C, blood pressure, and LDL cholesterol levels and had near-perfect compliance with national standards for diabetes care. This was accomplished in a federally qualified health center treating primarily indigent and transient Hispanic and Native-American populations. This study demonstrates the positive effect of clinically trained pharmacists in managing patients with diabetes and common comorbid conditions.

Pharmaceutical Care Concept

Pharmaceutical Care goal is to improve clinical outcome of patient by optimization of drug therapy outcome.

The pharmaceutical care task are counseling, pharmacotherapy planing, drug monitoring, home visit and telephone care.

Example
Patients were randomly assigned to a pharmacist-involved group (treatment) or a group with no pharmacist involvement (control). Pre- and post-test BPs, tablet counts, lifestyle modifications, and pharmacists' recommendations were recorded.
Hypertensive patients who received pharmacist input achieved a significantly greater benefit in BP reduction, BP control, and improvement in adherence rate and lifestyle modification.

HYPERTENSION

Pharmacist Involvement in Primary Care Improves Hypertensive Patient Clinical Outcomes

Phayom Sookaneknun, PharmD
The Annals of Pharmacotherapy: Vol. 38, No. 12, pp. 2023-2028. DOI 10.1345/aph.1D605
© 2004 Harvey Whitney Books Company.

How to be a great pharmacist ?

If you want to be a great pharmacist. You shoul be do something to increase your skill and knownlege such as the paper reading, communiction skills and pharmacotherapy knownlege.

The first step of great pharmacist way is learning the Pharmacotherapeutics subject and epidermology or Clinical trial concept.

The next step is learning by doing by used case study from textbook and talk with your patients. The importance thing that pharmacist must keep in mind is " How to make better QOL of patients or more clinical outcome?"

Example
Clinic-based pharmacists offered support to patients with diabetes through direct teaching about diabetes, frequent phone follow-up, medication algorithms, and use of a database that tracked patient outcomes and actively identified opportunities to improve care.
In conclusion, a pharmacist-based diabetes care program integrated into primary care practice significantly reduced HbA1c among patients with diabetes and poor glucose control.

Pharmacist Led, Primary Care-Based Disease Management Improves Hemoglobin Aic in High-Risk Patients With Diabetes

Russell Rothman, MD, MPP

Betsy Bryant, PharmD, CDE

Department of Medicine, University of North Carolina, Chapel Hill, NC

Cheryl Horlen, PharmD

School of Pharmacy, Campbell University, Buies Creek, NC

Michael Pignone, MD, MPH

Division of General Internal Medicine, University of North Carolina, Chapel Hill, NC

American Journal of Medical Quality, Vol. 18, No. 2, 51-58 (2003)
DOI: 10.1177/106286060301800202
© 2003 American College of Medical Quality

Pharmacist Participation on Physician Rounds and Adverse Drug Events in the Intensive Care Unit

In traditional hospital practice most of the burden of drug therapy decision making falls on the physician. However, studies have shown that physicians sometimes make errors in prescribing drugs.1-2 While most errors are harmless or are intercepted, some result in adverse drug events (ADEs). The pharmacist's role in prescribing is typically reactive: responding to prescription errors long after the decision has been made for patients about whom he or she has little direct clinical knowledge. Thus, the specialized knowledge of the pharmacist is not utilized when it would be most useful: at the time of ordering.

Studies show that pharmacist retrospective review of medication orders prevents errors.3-5 However, the pharmacist's impact might be substantially greater if he or she could provide input earlier, at the time of prescribing. It has been shown that pharmacist consultation with physicians and others in an intensive care unit (ICU) resulted in a net saving from reduced drug use of $10,011 in a 3-month period.6 However, we know of no controlled studies that have evaluated the effect of pharmacist participation on the key outcome measure of error prevention—the rate of ADEs.

For these reasons, we conducted a controlled clinical trial of the efficacy of pharmacist participation in physician rounds in a medical ICU as part of a continuing study of systems changes to prevent ADEs. The ADE rate is higher among patients in ICUs, both because they have pathophysiological abnormalities and often receive many drugs.

We asked the following questions: (1) Is pharmacist participation on rounds associated with a reduction in the rate of preventable ADEs? (2) What types of interventions does the pharmacist make? and (3) Is pharmacist participation on ICU rounds accepted by physicians and nurses?

Comments

In previous studies, we demonstrated that nearly half of preventable ADEs resulted from errors in the prescribing process.1 Prescribing errors frequently have a cascade effect, causing errors downstream in dispensing or administration. The major cause of prescribing errors was physicians' lack of essential drug and patient information at the time of ordering.2

One method of providing such information is computerized physician order entry, which has been shown to reduce the rate of serious medication errors by more than half.9 Evans et al10 have demonstrated that a computer-assisted management program for antibiotics can substantially reduce excessive use and misuse of antibiotics as well as reduce length of hospital stay and costs. However, most hospitals do not yet have computerized ordering by physicians, so incorporation of the pharmacist into the patient care team is a more feasible alternative at present, especially in units with high medication use.

We estimated the financial impact of the 66% reduction in ADEs. The cost of an ADE has been estimated at $2000 to $2500 per event in 1993.11-12 However, the cost of a preventable ADE, one due to an error, was estimated at $4685.9 For the year 1995 , we estimate that 58 ADEs were prevented. At $4685 each, the cost reduction in this single unit would be approximately $270,000 per year. The intervention required no additional resources and represented a different use of the existing pharmacist's time. Rather than spending time checking and correcting orders after they had been sent to the pharmacy, the pharmacist was involved at the time the order was written. While participating in rounds as a member of the patient care team, the pharmacist reduced ADEs both by preventing errors and by intercepting them. He prevented errors by providing information about doses, interactions, indications, and drug alternatives to physicians at the time of ordering. He intercepted errors by immediately reviewing all orders and correcting deficiencies before the orders were transmitted to the pharmacy. In addition, the pharmacist prevented nursing medication errors by providing ready consultation to the nursing staff and teaching drug safety.

Finally, the on-site pharmacist took overall responsibility for medication safety, spotting unsafe conditions and identifying needs for process improvement. For example, during the study period the pharmacist identified 12 systems errors in pharmacy function and 6 ADEs that probably would not have otherwise been discovered.

The presence of the pharmacist on rounds was well accepted by physicians, as evidenced by the fact that 99% of the recommendations were accepted. While staff perceptions were not evaluated systematically, in our experience, nurses also accepted this role easily, appreciating the reduction in extra work, such as telephoning physicians to have orders corrected. The pharmacist in this study had to overcome the traditional impression of the medical staff that pharmacists may be primarily concerned with costs. This academic medical ICU environment had the added challenge of dealing with a new group of house staff, fellows, and attending physicians every few weeks. In ICUs where the attending physicians are permanent and fellows are assigned for many months, acceptance might be enhanced.

Our study has several limitations. We studied only 1 ICU in 1 teaching hospital. Adverse drug events are more common in teaching hospitals than in community hospitals13 and occur more frequently in ICUs,1 so these findings are not generalizable to all types of units or all types of hospitals. However, the magnitude of the impact of the pharmacist's presence was so great that a substantial effect would probably be found in ICUs in other hospitals. Second, our results do not represent the full extent of preventable ADEs, since record review does not capture all events, nor does it capture most potential ADEs, the "near misses," because they are seldom recorded in patient charts. Third, physicians and nurses in this ICU function as a team and make rounds together. Pharmacist participation would be more difficult to arrange in units where multiple physicians make rounds at different times. Finally, the success of the pharmacist intervention depends on interpersonal relationships. Thus, the personality and cooperativeness of the pharmacist and the medical staff are critical factors in making this system work, especially at the beginning. Similar prevention of ADEs prompted by a designated ICU pharmacist probably would be less likely to occur in ICUs in which staff are not part of a multidisciplinary team and when ICU staff are not open to the important role that the pharmacist can play in optimizing ICU management.

We conclude that participation of a pharmacist on medical rounds can be a powerful means of reducing the risk of ADEs.

ADMISSION OR DISCHARGE MEDICATION RECONCILIATION

Medication review and reconciliation was the primary target of 11 studies.28-38 In the 2 admission interventions, Nester and Hale28 found that medication histories taken by pharmacists, as opposed to nurses, resulted in more accurate medication and allergy information, identified allergy history errors more frequently, and entered allergy information into the computer more quickly, with no difference in drug interactions or ADRs. In a study from Australia, Stowasser et al29 implemented a medication liaison service to improve communication between outpatient physicians and pharmacists and the inpatient team at admission and discharge. The intervention group was more likely to have a pharmacist intervene or change at least 1 medication during hospitalization, with no effect on LOS or mortality. At 30 days, the intervention group had fewer health care visits, nonsignificant reduction in readmissions, and no overall change in health status.

Another 9 studies focused on discharge counseling. Smith et al30 performed home visits and assessed pharmacist discharge counseling on patient medication-taking behavior and found significantly better levels of medication adherence (P<.01), although 75% of patients in the intervention group and 96% of patients in the control group were not taking medications as prescribed. Bolas et al31 compared standard discharge planning with pharmacist discharge counseling coupled with a discharge letter from the inpatient physician to the patient's general practitioner. Significant improvement was noted in the correlation between discharge and home medications 10 to 14 days after discharge, as well as knowledge of drug name, dosage, and frequency, with no difference in readmission rates. In a Veterans Administration hospital discharge counseling intervention, Williford and Johnson32 reported that patients were no more knowledgeable or compliant at the 6-week follow-up.

In a study by Lipton and Bird,33 pharmacists reviewed hospital records, consulted with physicians, provided discharge counseling, and made 4 follow-up telephone calls after discharge. At 2 months, patient medication knowledge was higher in the intervention group. At 3 months, patients in the intervention group compared with those in the control group received fewer medications (5.16 vs 6.75; P<.001) and fewer daily doses (8.30 vs 12.04; P<.001), and reported fewer missed doses (8% vs 22%; P<.001); resource use was not affected. From the same study, Lipton et al34 evaluated a 236-patient sample in 6 domains of medication appropriateness. Patients in the intervention group were less likely to have one or more prescribing problems in any category, in appropriateness or in dosage.
Johnston et al35 evaluated the role of pharmacist discharge counseling on medication knowledge in older patients. An evaluation immediately before discharge and a recall questionnaire found that the percentage of critical items correct for the pharmacist-counseled group was 93% compared with 77% in the control group (P = .02). Nazareth et al36 reported no differences in hospital readmissions, outpatient visits, or mortality at 3 or 6 months for a discharge pharmacist intervention to coordinate care with outpatient pharmacists and providers in patients older than 75 years. In a similar study, Al-Rashed et al37 enrolled 83 elderly patients at discharge and reported improvements in knowledge, compliance, outpatient visits, and hospital readmissions. In the most recent study of pharmacist counseling at discharge with telephone follow-up after 3 to 5 days, Schnipper et al reported fewer
preventable ADEs (1% vs 11%; P = .01) and fewer preventable medication-related emergency department visits or hospital readmissions (1% vs 8%; P = .03) at 30 days in the intervention group compared with the control group, with no difference in medication compliance.