Randal P. McDonough

Comprehensive Medication Therapy Management: Identifying and Resolving Drug-Related Issues in a Community Pharmacy

OBJECTIVE The aim of this study was to characterize comprehensive medication therapy management (MTM) involving a community pharmacy and local physicians by describing the drug-related issues encountered, identifying which medication types were associated with these issues, and listing the actions taken by physicians and pharmacists to address them. METHODS In the MTM program studied, community pharmacists and physicians worked together to manage the drug therapy of ambulatory Iowa Medicaid recipients dispensed > or =4 medications for chronic conditions by a community pharmacy. After initial assessment, pharmacists made written recommendations to the patients physician, and the physicians subsequently responded. Data were extracted from pharmacy records for patients who made > or =1 visit during the first 2 years of the program. Collected data included patient demographics, number of chronic conditions and medications at enrollment, type and number of drug-related issues, medication category, pharmacist recommendations, and physician acceptance of recommendations. RESULTS Data were gathered for 150 patients. The mean (SD) age was 54.4 (19.4) years and 74.0% were female. They were taking a mean (SD) of 9.3 (4.6) medications and had a mean (SD) of 6.1 (3.1) medical conditions at enrollment. A total of 886 drug-related issues were classified into 7 categories: inappropriate adherence (25.9%), needs additional therapy (22.0%), wrong drug (13.2%), unnecessary drug therapy (12.9%), adverse drug reaction (11.1%), dose too low (9.7%), and dose too high (5.3%). Overall, physicians accepted 313 (47.4%) of the 659 recommendations to alter drug therapy made by pharmacists, with the highest rates of agreement to stop or change a medication (50.3% and 50.0%, respectively) and the lowest rate of agreement to start a new medication (41.7%). CONCLUSION The MTM program showed that drug therapy for ambulatory patients taking multiple medications to treat chronic conditions can be improved through collaboration between physicians and community pharmacists.

Influential Characteristics of Physician/Pharmacist Collaborative Relationships

BACKGROUND A theoretical model of physician/pharmacist collaborative relationships, driven by 3 groups of relationship characteristics termed participant, context, and exchange, has been developed. There are no studies that have examined the types of characteristics which most influence development of collaborative relationships between physicians and pharmacists. OBJECTIVE To test the model and determine which drivers most influence physician/pharmacist collaboration. METHODS Data on the relationship drivers and collaborative practice were collected via a mailed survey of a random sample of 1000 primary care physicians in Iowa. Participant variables include demographics; context drivers refer to the practice environment and professional interactions between physicians and pharmacists. Exchange characteristics describe the nature of social exchange and were elicited using scores from 3 domains (relationship initiation, trustworthiness, role specification) of the Physician/Pharmacist Collaboration Instrument (PPCI). Five additional questions asked about the physicians collaborative practice with a pharmacist. Hierarchical linear regression analysis was performed with collaborative practice as the dependent variable and measures of participant, context, and exchange drivers as independent variables. RESULTS Three hundred forty usable surveys (34%) were returned. Almost 70% of the respondents were male and aged 45.8 ± 9.9 years (mean ± SD). The majority were family practice physicians (72.1%) in private practice (67.3%). Regression analyses produced an R2 = 0.804 (p < 0.001). Significant predictors in the model were internal medicine physicians, professional interaction with a pharmacist, and the 3 domains of exchange drivers from the PPCI (p < 0.05). CONCLUSIONS Although participant and context factors influenced physician/pharmacist collaborative relationships, exchange characteristics were the most influential relationship drivers. Role specification, trustworthiness, and relationship initiation were positively associated with physician/pharmacist collaborative practice. Recognition of these drivers may help pharmacists who are developing collaborative working relationships with physicians. But, studies are needed to delineate other factors that may influence physician/pharmacist relationships.

Beyond the 4Ps: Using Relationship Marketing to Build Value and Demand for Pharmacy Services

More than a decade ago, Hepler and Strand1,2 introduced the concept that the therapeutic relationship between pharmacist and patient was an integral component of pharmaceutical care. They saw pharmaceutical care as “a covenantal relationship between a patient and a pharmacist in which the pharmacist performs drug use control functions (with appropriate knowledge and skill) governed by the awareness of and commitment to the patient’s interest.”1,3 An empathetic and trusting pharmacist–patient relationship is now widely recognized as the cornerstone of pharmaceutical care. Far less appreciated, however, is how important the pharmacist–patient relationship is for successfully marketing pharmacy-based clinical services. Close collaborative relationships with patients, physicians, and other potential partners (i.e., other stakeholders in patient care) are the keys to creating and sustaining demand for pharmacy services on a long-term basis. Ideally, a network of mutually rewarding relationships should form the foundation of a pharmaceutical care marketing plan. In the pharmacy setting, interactions are increasingly anonymous, as more prescriptions are being filled through Internet pharmacies and automated refill programs. Pharmaceutical care, however, emphasizes a patient-centered focus that is mutually rewarding to all parties. Similarly, relationship-centered marketing focuses on the pharmacist-patient bond and represents a major shift in practice from traditional marketing, which emphasizes discrete (one sale at a time) and often impersonal exchanges between organizations and customers. In this article, we describe how to use relationship marketing to create and maintain a network of productive relationships with selected groups of patients and other partners to expand the delivery of pharmaceutical care services. The article also draws upon the first-hand experience of one of the authors (McDonough) and other pharmacists at Main at Locust Pharmacy in Davenport, Iowa, who used this innovative marketing approach to increase patient participation in a Weight Control and Wellness Program in their pharmacy clinic.

Three-year financial analysis of pharmacy services at an independent community pharmacy

OBJECTIVE To assess the financial performance of pharmacy services including vaccinations, cholesterol screenings, medication therapy management (MTM), adherence management services, employee health fairs, and compounding services provided by an independent community pharmacy. METHODS Three years (2008-10) of pharmacy records were examined to determine the total revenue and costs of each service. Costs included products, materials, labor, marketing, overhead, equipment, reference materials, and fax/phone usage. Costs were allocated to each service using accepted principles (e.g., time for labor). Depending on the service, the total revenue was calculated by multiplying the frequency of the service by the revenue per patient or by adding the total revenue received. A sensitivity analysis was conducted for the adherence management services to account for average dispensing net profit. RESULTS 7 of 11 pharmacy services showed a net profit each year. Those services include influenza and herpes zoster immunization services, MTM, two adherence management services, employee health fairs, and prescription compounding services. The services that realized a net loss included the pneumococcal immunization service, cholesterol screenings, and two adherence management services. The sensitivity analysis showed that all adherence services had a net gain when average dispensing net profit was included. CONCLUSION Most of the pharmacist services had an annual positive net gain. It seems likely that these services can be sustained. Further cost management, such as reducing labor costs, could improve the viability of services with net losses. However, even with greater efficiency, external factors such as competition and reimbursement challenge the sustainability of these services.

Identification of Essential Elements in the Documentation of Pharmacist-Provided Care

OBJECTIVES To develop guidelines for the documentation elements that need to be included in any record of pharmacist-provided care to allow the quality of the care to be assessed and to describe the use of these guidelines to improve the quality of pharmacist documentation. DESIGN An initial list of 85 potential documentation elements, developed through a review of the literature, was validated by a group of pharmacy practitioners. Then, through three rounds of a Delphi process and a group meeting, a panel of experts reached consensus on a refined list of 27 documentation data elements. RESULTS The documentation elements were formatted into a one-page Tool for Evaluation of Documentation (TED). The TED is a checklist for assessing the completeness of the documentation of pharmacist-provided care. CONCLUSION The TED and the consensus-building methodology used in the development of this tool can serve as cornerstones of a quality assessment process for documentation of pharmacist-provided care, enable further assessment of the quality of care, and, ultimately, be used to measure the impact of pharmacist-provided care on patient outcomes. Our results should provide guidance both to pharmacists providing care and to organizations that assess the quality of that care.

Retrospective financial analysis of medication therapy management services from the pharmacy's perspective

OBJECTIVE To determine the net financial gain or loss for medication therapy management (MTM) services provided to patients by an independent community pharmacy during 16 months of operation. DESIGN Retrospective study. SETTING Independent community pharmacy in Iowa City, IA, from September 1, 2006, to December 31, 2007. PATIENTS Patients receiving MTM services during the specified period who had proper documentation of reimbursement for the services. INTERVENTION MTM services were provided to the patient and documented by the pharmacist or student pharmacist. MAIN OUTCOME MEASURE Net financial gains or losses for providing MTM services. Sensitivity analyses included costs that might be incurred under various conditions of operation. RESULTS 103 initial and 88 follow-up MTM visits were conducted during a 16-month time period. The total cost for these services to the pharmacy was

Using Personal Selling Skills to Promote Pharmacy Services Everyday encounters with patients offer valuable opportunities to build demand for pharmacy services and impart the value of pharmaceutical care.

11,191.72. Total revenue from these services was

Exploring relationships among pharmacy service use, patronage motives, and patient satisfaction

11,195.00; therefore, the pharmacy experienced a net financial gain of

Retrospective financial analysis of a herpes zoster vaccination program from an independent community pharmacy perspective

3.28. Sensitivity analyses were conducted, revealing the net gain/loss to the pharmacy if a student pharmacist was used and the net gain/loss if the pharmacist needed extra training to provide the services. Using a student pharmacist resulted in a net gain of

Community pharmacist assessment of 10-year risk of coronary heart disease for union workers and their dependents

6,308.48, while extra training for the pharmacist resulted in a net loss of