Costs of implementing pharmaceutical care in community pharmacies.

OBJECTIVE: To estimate the costs and benefits to community pharmacies of converting a traditional practice into one based on pharmaceutical care. SETTING: Community-based ambulatory care pharmacies. PRACTICE DESCRIPTION: Community pharmacy. PRACTICE INNOVATION: Pharmaceutical care. MAIN OUTCOME MEASURES: Costs incurred and revenues received. DESIGN: Twenty-five community pharmacies that had made the transition from traditional practice to one based on pharmaceutical care returned a survey providing data on the costs and revenues associated with the transition. RESULTS: Mean total cost of making the conversion for the 25 pharmacies was $36,207. The largest cost component associated with the transition was personnel, which had a mean cost of $16,512 per pharmacy. Mean revenues received for pharmaceutical care by these 25 pharmacies was $3,687, mainly for disease management services. Pharmacies that spent more on the conversions, and used brochures and physician detailing as well as consultants and franschises, tended to be more successful in generating revenues from pharmaceutical care. CONCLUSION: Most pharmacies that have made the conversion to pharmaceutical care have not experienced an increase in profits as a result of that conversion. More effort needs to be directed toward improving the flow of revenues obtained from providing pharmaceutical care.

Analysis of the practice of nutrition support pharmacy specialists.

In 1988 the Board of Pharmaceutical Specialities (BPS) recognized nutrition support pharmacy practice (NSPP) as one of four specialty areas in pharmacy. The BPS appointed a specialty council to develop and manage the process for board certification of qualified specialists. One step was to identify and validate activities performed by the specialists. This was accomplished by conducting a study that delineated the role of these practitioners and also provided information for developing a blueprint for a certification examination. The results revealed the types of practice settings, education, and training for specialists, and the distribution of professional time devoted to nutrition support activities.

Appropriate use of heparin. Empiric vs nomogram-based dosing.

BACKGROUND: A study involving two groups of patients with cardiovascular disease was conducted to compare empiric (clinician-directed) heparin therapy with therapy based on a nomogram-determined dosage. The comparison was based on (1) the average weight-referenced infusion rate yielding a therapeutic activated partial thromboplastin time (APTT) and (2) the time required to reach a therapeutic APTT (55 to 95 seconds) after empiric or nomogram-based heparin therapy was initiated. METHODS: Data were collected for patients admitted to the cardiology service at a university health science center in two phases: phase 1 (April 1 through June 30, 1992), involving 95 patients receiving heparin therapy, with 88 patients included in the data analysis, and phase 2 (March 11 through June 11, 1993), involving 156 patients receiving heparin therapy, with 45 patients receiving nomogram-guided therapy included in the data analysis. RESULTS: In phase 1, 66 patients (75.0%) achieved a therapeutic APTT some time during their heparin therapy, with an average time to therapeutic APTT of 20.7 + 19.1 hours. Regression analysis demonstrated a statistically significant relationship between the heparin infusion rate at the time of the patient's first therapeutic APTT and the patient's total body weight (r2 = .3043). An initial infusion rate based on total body weight (13 U/kg per hour) was therefore used as the basis for the nomogram in phase 2. In phase 2, 41 patients (91.1%) achieved a therapeutic APTT at some time during their heparin therapy, with an average time to therapeutic APTT of 13.1 + 11.9 hours, statistically significantly shorter than that in phase 1. A greater proportion of patients in phase 2 compared with patients in phase 1 reached the therapeutic range within 12 hours (62.2% vs 34.1%) and within 24 hours (77.8% vs 54.5%). CONCLUSIONS: Use of a weight-based nomogram to determine the initial and maintenance heparin infusion rates was associated with a higher percentage of patients admitted to the cardiology service reaching the targeted therapeutic APTT range at a time earlier in the course of therapy compared with empiric dosing.

An evaluation of the sensitivity of five home pregnancy tests to known concentrations of human chorionic gonadotropin.

A study was conducted to evaluate the sensitivity of the five commercially available home pregnancy testing kits. Known amounts of human chorionic gonadotropin (hCG) were diluted in pooled, sterile male urine. Varying concentrations of hCG were randomly assigned to 100 kits of each of the five brands. The test results were read independently by three individuals who were blinded to the hCG concentrations. Statistical analysis were based on the majority vote of the readers. The rank-ordered sensitivity of the five home pregnancy tests, expressed as the proportion of positive results for the range of hCG concentrations studied, was as follows: (1) Predictor, (2) e.p.t., (3) Acu-Test, (4) Answer, and (5) Daisy 2. Overall, Predictor and e.p.t. appear to be more accurate than Acu-Test or Answer. Only Daisy 2 was found to be significantly different from the other brands. However, the currently marketed Daisy 2 pregnancy test is manufactured by a different company.

Pharmacist-managed allergy desensitization program.

A pharmacist-managed immunotherapy program for ambulatory atopic patients is described. Pharmacists in a network of three health centers recommended that they assume management of the allergy desensitization program when they recognized problems with the existing program. Guidelines for the immunotherapy service were developed and approved by the pharmacy, therapeutics, and standing orders committee. Patients, already tested by an allergist, are referred to the pharmacists for the administration of their immunotherapy. Under the guidelines for the program, pharmacists collect and record the patients' history, assess the patients' knowledge of allergy desensitization, administer the allergens, examine the injection site, question the patients about symptoms, and initiate treatment of local and systemic reactions. A physician is available for consultation and for treatment of life-threatened adverse reactions. Following any reaction, the pharmacist adjusts the next antigen dose accordingly. Typical charges for these services are $10-15 for the first visit, and $3.50 for subsequent visits. The pharmacists spend about 30 minutes of their time for the initial visits, and 10 minutes for subsequent visits. The time spent by physicians is negligible, and there is no charge for their consultations. Patients under the care of the pharmacists rarely wait more than 15 minutes for an appointment. This service has been well accepted by patients, physicians, and mid-level practitioners. Pharmacists are using their knowledge and skills to provide a direct patient-care service, and they are being reimbursed for a nondispensing activity.

Pharmaceutical services in hospices.

Hospices were surveyed to identify the types of pharmaceutical services provided. The directors of 75 hospice organizations were sent questionnaires regarding: (1) the type and scope of pharmaceutical services and (2) their conception of the future of the hospice movement. Of the 48 usable responses, 37 reported pharmacist affiliation. Of the 11 organizations that did not have a pharmacist affiliated, 10 reported they anticipated using a pharmacist's services in the future. Most (68%) pharmacists who worked in hospices were consultants. Pharmaceutical services included the development of policies and procedures regarding drug storage and handling, inservice education, drug information, and patient education. Of the organizations without a pharmacist, 91% provided only outpatient care; of hospices with pharmacists, 51% provided outpatient, 14% inpatient, and 36% outpatient and inpatient care. Forty-six percent of the hospice directors considered the pharmacist affiliated with their organization to be a member of the interdisciplinary team; 55% of such pharmacists worked full-time with the hospice. Hospice directors expressed a need for greater pharmacist involvement in inservice education, staff consultation, and research on pain.

Emergency-room services for a community health center.

The development and maintenance of an organized system of emergency care in isolated ambulatory health-care centers are described. A system of three community health centers, staffed chiefly by midlevel practitioners (i.e., physician's associates and nurse practitioners), had a need to provide occasional emergency care to patients. Emergency care needed to be provided (for up to one hour) until an ambulance arrived to transport the patient to a hospital. A system of emergency care, consisting of treatment protocols, a drug manual, equipment and medications, and a program for periodic inservice education was developed by physicians, midlevel practitioners, and pharmacists. Weekly checks of the supplies and medications are conducted. Lists of supplies and medications stocked, and a sample drug monograph, are included in the paper. The program has resulted in more efficient emergency care, including less confusion in executing and documenting treatment.