EXPERT ANALYSIS AT ACP INTERNAL MEDICINE
SAN DIEGO (FRONTLINE MEDICAL NEWS) – Incorporating pharmacists into primary care offices has the potential to significantly impact patient care and save health care costs, according to Hae Mi Choe, PharmD.
Drug-related morbidity in the United States costs an estimated $290 billion annually, or about 13% of total health care expenditures, said Dr. Choe, associate dean at the University of Michigan College of Pharmacy and director of pharmacy innovations and partnerships at the University of Michigan Medical Group, Ann Arbor.
“Adverse events occur in about one-third of patients in ambulatory care, and we find that about 40% could be prevented,” she said at the annual meeting of the American College of Physicians. “Medication nonadherence drives the largest avoidable health care cost, which is about $100 billion. Also, delays in applying evidence-based treatment to patients can contribute an additional $40 billion.”
Dr. Choe described her experience helping to create a group practice model at the university health system for clinical pharmacists as part of the patient-centered medical home movement.
A total of 11 pharmacists are embedded in 14 primary care clinics in the University of Michigan Health System (now known as Michigan Medicine) to provide disease management and comprehensive medication review services. The pharmacists’ time at each site varies depending on patient volume, but typically ranges from 1 to 3 days per week.
They work to identify patients struggling to manage their diabetes, hypertension, or hyperlipidemia. “For patients who may not have reached their HbA1c goal, for instance, we may reach out to the physician and say, ‘Do you think Mrs. Jones would benefit from seeing a pharmacist?’ ” she said.
For comprehensive medication review, pharmacists schedule two visits. The first involves sitting down with the patient to review all of their medications, “trying to understand the patients’ perception of their medication, their preference in how they go about their treatment regimen, their understanding of the disease state, and identify potential barriers to treatment like medication cost,” Dr. Choe explained.
“Then we schedule the patient back in 2 weeks, after we’ve discussed issues with physicians and created a treatment plan,” she continued. “At that time, we discuss new treatment plan to improve efficacy, safety, and lower drug costs.”
Combined, both visits amount to 75-90 minutes of the pharmacist’s time.
“We try to provide comprehensive medication review at least once a year for complex patients,” she said. “It’s our version of an annual physical exam. One patient I saw was taking 32 medications prescribed by nine different specialists. She was taking her medication eight times per day.”
Another patient who came in for a comprehensive medication review transported his drugs in a suitcase. “He told me that he was about to go to Florida, and that the suitcase for his medications was bigger than the one for his clothes,” Dr. Choe said.
“You’d be surprised what patients take that you were not aware of,” she added. “Research shows that up to 50% of the time, patients do not take medications as prescribed. For antihypertensives, roughly one-quarter of patients don’t fill the prescription to begin with, and another one-quarter don’t take it as prescribed. That’s 50% right there.”
Pharmacists in the Michigan Medicine practice model have full access to the health system’s electronic medical record, including bidirectional communication with physicians.
“We also have population-level data, so if I wanted to drill down on clinic A and ask, who in clinic A is not achieving HbA1c, blood pressure, or other quality metrics, with a click of a button we can drill down to that population base,” she said. The pharmacists have been granted special clinical privileges, including the ability to initiate medication, adjust dosing, and discontinue therapy based on delegation protocols.
When Dr. Choe and her associates analyzed 2,674 interventions made during the first year of the program’s implementation, 50% involved increasing a dose, followed by adding a medication (20%), decreasing a dose (13%), deleting a medication (9%), and optimizing a medication regimen (8%). In addition, patients with a baseline HbA1c of greater than 7% experienced a 1% drop in their HbA1c level. Results were similar for patients whose baseline HbA1c level was greater than 8% and greater than 9% (drops of 1.4% and 1.9%, respectively).
The pharmacist program has expanded to Michigan Medicine chronic kidney disease clinics, outpatient psychiatric clinic, anticoagulation services, transitions of care services, palliative care services, transplant services, transplant clinics, oncology clinics, and telehealth services, Dr. Choe said.
For clinicians looking to embed pharmacists into their clinics, she recommended identifying key stakeholders with whom to collaborate.
“That could be a physician champion, and having a lead pharmacist who not only has the strong clinical ability but leadership skills to build a program,” she said. “You would also benefit from having someone in your team with a clinical operation background, and someone with quality and data expertise. Start small and aim for a bigger impact.”
Dr. Choe reported having no financial disclosures.