Risk-based strategy for outpatient pharmacy practice: Focus on opioids.

OBJECTIVES: To highlight the limitations of community pharmacy practice and to propose a system change by implementing a risk-assessment method and management strategy for opioids in this arena. DATA SOURCES: Selected by the author. SUMMARY: Numerous studies show that the U.S. health care system is subject to a high rate of drug misadventures involving primarily low therapeutic index drugs, especially opioids. Currently proposed approaches to managing opioids focus on access control, but without a broader consideration of patient-use problems that lead to morbidity and mortality. While pharmacists are well-trained health professionals, their primary focus has been on drug distribution rather than proper use. This article highlights the limitations in contemporary community pharmacy practice that likely contribute to the problem of opioid misuse and resultant morbidity. CONCLUSION: A new model of practice is proposed whereby the most dangerous agents such as opioids are preidentified for a more formalized risk-based strategy focused upon optimal patient education and required follow-up.

Provision of pain management by a pharmacist with prescribing authority.

PURPOSE: The clinical and financial outcomes of a pain clinic managed by a pharmacist with prescribing authority are described. SUMMARY: Pharmacist clinicians in a for-profit, integrated health system recently received permission to bill for their services in certain ambulatory clinics. A pharmacist clinician, who had an individual Drug Enforcement Administration number and whose services are billable under New Mexico law, was chosen to assume the medication management responsibilities in a clinic where 90% of the patient population is treated for chronic non-cancer-related pain. No additional personnel were needed, and no additional space was required, eliminating overhead for the space and utilities needed for operating a new clinic. With the ability to bill for the pharmacist clinician's services, a new model for justification of clinical pharmacy services was developed for the ambulatory care clinics. The revenue generated was tracked by a medical billing system, and clinical outcomes were tracked using the clinic's database for patients' individual visual analogue scale (VAS) pain scores. Between June 2004 and June 2005, an average of 18 patients were seen by the pharmacist clinician each day. The clinic generated 107,550 dollars of actual revenue and saved the health plan over 450,000 dollars. There was a consistent decrease in mean VAS pain scores with continued visits. CONCLUSION: Patients with chronic non-cancer-related pain were managed effectively by a pharmacist with prescribing authority and refill authorization in a pain management clinic. The favorable clinical outcomes, revenue generated, and cost savings achieved justified the pharmacist clinician's services in this health system.

Use of herbal medicine by elderly Hispanic and non-Hispanic white patients.

STUDY OBJECTIVES: To determine the types and prevalence of herbal medicines used by Hispanic and non-Hispanic white individuals aged 65 years and older. Secondary objectives were to compare herbal medicine use according to ethnicity, sex, age, socioeconomic status, and education level, and to determine patients' beliefs about herbal medicines. Use of nonphysician health care providers such as acupuncturists and chiropractors also was assessed. METHODS: Data for a cross-sectional, interviewer-administered survey were collected at the University of New Mexico Senior Health Center, an ambulatory health care clinic, in Albuquerque, New Mexico, from February 1996-January 1997. To participate in the study, patients had to be at least 65 years of age, established patients at the clinic, and live independently in a community dwelling. They were excluded if they had dementia, lived in an institution, or belonged to any ethnic group other than Hispanic or non-Hispanic white. Ethnicity was determined by asking the patients in which ethnic group they identified themselves. RESULTS: A total of 186 patients were surveyed: 84 Hispanic (34 men, 50 women) and 102 non-Hispanic white (47 men, 55 women). Of the 186 patients, 91 (49%) admitted to having taken herbal medicines in the previous year. The most common were spearmint, chamomile, aloe vera, garlic, brook-mint, osha, lavender, ginger, ginseng, and camphor. Most of the patients who used herbal medicines were 65-74 years of age and took them primarily for health care maintenance or self-perceived problems. CONCLUSION: As approximately half of the elderly patients stated that they used herbal medicines, health care providers should be knowledgeable about herbal remedies and provide reliable information to their patients about them in a nonjudgmental manner.

Advanced-practice pharmacists: practice characteristics and reimbursement of pharmacists certified for collaborative clinical practice in New Mexico and North Carolina.

PURPOSE The results of a survey assessing the practice settings, clinical activities, and reimbursement experiences of pharmacists with advanced-practice designations are reported. METHODS A questionnaire was sent to all certified Pharmacist Clinicians in New Mexico and all Clinical Pharmacist Practitioners in North Carolina (a total of 189 pharmacists at the time of the survey in late 2008) to elicit information on practice settings, billing and reimbursement methods, collaborative drug therapy management (CDTM) protocols, and other issues. RESULTS Of the 189 targeted pharmacists, 64 (34%) responded to the survey. On average, the reported interval from pharmacist licensure to certification as an advanced practitioner was 11 years. The majority of survey participants were practicing in community or institutional settings, most often hospital clinics or physician offices. About two thirds of the respondents indicated that their employer handled the billing of their services using standard evaluation and management codes, with estimated total monthly billings averaging $6500. At the time of the survey, about 80% of the respondents were engaged in a CDTM protocol. The survey results suggest that pharmacists with advanced-practice designations are perceived favorably by patients and physicians and their services are in high demand, but more than one third of respondents indicated a need to justify their advanced-practice positions to administrators. CONCLUSION Pharmacists with advanced-practice designations are providing clinical services in various settings under collaborative practice arrangements that include prescribing privileges. Despite growing patient and physician acceptance, reimbursement challenges continue to be a barrier to wider use of CDTM programs.