Can you measure success of clinical pharmacy

[ZpackSux]

in terms of financial impact it has on a healthcare system?

I'm not speaking of soft dollars or the potential savings in terms of prevention of future lawsuits or ADRs. How about an actual amount bottom line $ saved through clinical pharmacy programs?

Discuss.

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[ZpackSux]

in terms of financial impact it has on a healthcare system?

I'm not speaking of soft dollars or the potential savings in terms of prevention of future lawsuits or ADRs. How about an actual amount bottom line $ saved through clinical pharmacy programs?

Discuss.

I see that the schools of pharmacy are doing a great job...

 

[bananaface]

Yes. It's done some places. They have this fat chart at one local hospital here that shows the value to the hospital of all services. Codes are a big fat negative value. Apparently it's cheaper for the hospital if you are a DNR.

 

[sdn1977]

I see that the schools of pharmacy are doing a great job...

Frankly, I'm not sure students or even very recent grads could really answer this well. My personal experience is yes...I've been able to objectively evaluate & present cost savings due to involvement as a member of a P&T committee & as a pharmacist in the ICU & OR. I've had clinical involvement within out mental health unit & SNF, but since I acted only as one of many clinical pharmacists & not as the main contact person, my input was not solicited when it came to budgetary & formulary choices. Our new grads are very rarely put on committees such as P&T or the subcommittees of medicine until they've worked a few years.

However, I did have the unique experience of having my hospital be sold during my time there to a large multihospital health care corporation. The budgetary & formulary choices became influenced by the contractual circumstance the total corporation was involved in - not just my own site, which was far different when we were a stand alone hospital.

If your request for discussion is getting at wanting to know if they are learning how to make formulary drug choices based not just on clinical evidence, but to also consider the financial, contractual & bundling arrangements - perhaps you should have phrased it that way. I'm not sure if students really do get exposure to this - especially in pharmacy school. As a preceptor, I don't give them this exposure because its not in their objectives & their time with me is limited as it is.

However, if they do an administrative residency.....or even a clinical residency now I come to think about it - yes...it should certainly be included in their exposure!

 

[WVUPharm2007]

Actually, they devote an entire class to it now, most call it "Pharmacoeconomics" or something like that. It's mostly common sense crap. Some of the thoery behind it seems crappy to me though. Especially rating treatment in quality-of-life-years. It's way too subjective for me.

 

[kwizard]

Actually, they devote an entire class to it now, most call it "Pharmacoeconomics" or something like that. It's mostly common sense crap. Some of the thoery behind it seems crappy to me though. Especially rating treatment in quality-of-life-years. It's way too subjective for me.

I'd agree that the pharmaeconomics is a little hard to rationalize from time-to-time due to all of the potential confounders. However if you have defined outcomes in the short term make justification for clinical pharmacy services a lot easier. For instance...at Univ of KY school of pharmacy they have the REACH program where some faculty from the school do a lot of various types of med management, but one of their biggest projects is targeting frequent readmits to the hospital and review their drug regimen for potential problems (polypharmacy, compliance, etc). Since endpoint is repeat admissions w/i any defined period, justification/cost savings are quickly noticed in the number of decreased admissions (by pts who may not have a reimbursable service if they were readmitted). Basically, I think that hospitals don't get reimbursed for any pts that are readmitted w/i 72hrs of their most recent discharge so if you can cut these readmits down than that would be automatic savings.

Other options is the whole therapeutic drug monitoring piece where the billing/reimbursement has a little ways to go, but at least it can be documented and you could minimized hospital days by appropriately managing therapy or discontinuing various drugs in certain cases (i.e. protocols for pharmacy to d/c metformin when Scr>1.5 (males? or 1.3(females) as an elevated SCr is likely to extend the admission until it normalizes). If you could actually get reimbursed for TDM or AC clinic in outpt setting I would think that would also serve as a revenue source as especially AC clinic are almost purely pharmacist ran in private and federal sector. Even in bridge therapy you could show some cost savings by minimizing the use for LMWH (pre-op) and just manage on warfarin and incr INR monitoring (maybe add one extra visit) to ensure appropriate levels prior to operation (obviously this latter method is a bit of a stretch).

To answer SDN1977's point, no I don't think justification of clinical pharmacy services gets enough time in pharmacy school or even in residency training. Like WVU mentioned the pharmacoeconomics classes have their shortcomings and providing cost-effective therapy is only one small piece of pharmacy training. We as a profession really need to become more aware of the business side (billing and reimbursement) in order for the profession to sustain itself and flourish in any setting that isn't directly related to our capacity to dispense medications. Easier said then done.

 

[sdn1977]

To further expand on your thoughts, Kwizard....I find we have a long way to go just on the pharmacotherapy management you gave as an example: metformin. Continued metformin use in the face of increased Crcl is not an unusual circumstance, but actual clinical issues secondary to this are not as common. However, this is a difficult concept to teach a student or even some residents I've had. They like to track labwork, but they don't think globally of why the labwork is what it is.

I often have post-op pts who will have an increase in Crcl & my students want to decrease famotidine doses & dc metformin. But...when I ask why the Crcl is high...they don't have a reasonable answer. However, the answer lies, usually in the operative record. The anesthesiologist has kept them a bit dry for various reasons. Within a day of replacing fluids...the Cr bounces back up & all is fine. Adjusting doses in the face of situations like this just extends stays & increases costs due to pharmacy generated lab orders (well - not for famotidine & metformin, but perhaps for amioglycosides...) These are not pharmacy costs, but lab costs, which often aren't correlated with pharmacy costs. Pharmacy generated labs & visits are far too frequent, IMO, in anticoag clinics because pharmacists don't have a good clinical handle on renal variations, factors influencing lab results & how often an abnormal lab results in morbidity, either outpt or requiring admission.

My point is protocols are good tools to have, but require good clinical judgement as to when to implement & when to ignore. I wish I could remember the phrase ZPack used when he was describing a candidate he was interviewing for a job who had all the right credentials, but just didn't have the ........which I interpreted to mean the wisdom to make use of her skills.

The interrelationship between pharmacoeconomics & pharmacotherapeutics is complex & will take time to become a reality. We've just touched here on inpt, but the issues translate to outpt retail settings as well.

So.....Zpack.....want to join in?

 

[lord999]

in terms of financial impact it has on a healthcare system?

I'm not speaking of soft dollars or the potential savings in terms of prevention of future lawsuits or ADRs. How about an actual amount bottom line $ saved through clinical pharmacy programs?

Discuss.

My program has earnestly tried to measure CEA of pharmaceutical care and clinical pharmacy for a couple of decades now.

Truth is, if one does the math, we are overpaid for this. There is also the question of how to value a "missed" incident. It's not quite as simple as saying that when you adjust a dose, you prevent a misfill.

My systems theory prof. has said that the existence of clinical pharmacy as a viable profession is a symptom of the wrong direction for the entire health care system. If there is that much variation in the process post-hoc that a pharmacist must tend to, then the process of medication prescribing and use is not controlled well at the front end.

If you think about it, most of the work clinical pharmacy does is not preventative in nature; it is capturing aspects of care that should have been already done. For clinical pharmacy to become viable, it should not be a post-hoc measure, it should be done concurrently or prior to a patient's entry into the process.

There's a couple of things out there, Asheville, the Iowa project, but the results can be argued from increased contact rather than anything we actually could contribute.

 

[lord999]

Actually, they devote an entire class to it now, most call it "Pharmacoeconomics" or something like that. It's mostly common sense crap. Some of the thoery behind it seems crappy to me though. Especially rating treatment in quality-of-life-years. It's way too subjective for me.

I completely agree with you. A lot of people have difficulty swallowing the QOL and HRQOL measurements. They are effectively dead subjects in economics at the moment because they are impossible to measure.

I do like what a person is willing to pay for a life-year though. Most people (even if it is beyond their means) will pay somewhere between $60K and $170K to avoid death this year. Whether this is applicable to daily life remains to be seen.

Unfortunately, we don't have time to get into the more interesting aspects of the subject because of time constraints (no need for economics, but lots of need for therapeutics).

 

[ZpackSux]

If I may interject,

SDN1977, you have a "clue." Pharmacy needs more people like you and Kwizard.

For many years, we beat our heads against the wall trying to justify the value of clinical pharmacy through documentation of interventions. However, this is viewed as 'Soft Money' by many CFOs which didn't really show the bottom line cost effectiveness but rather showed an arbitrary $ assigned to each task.

The bottom line $ saved in clinical pharmacy program shows up on Drug Utilization Cost per Pharmacy Adjusted Patient Days.

Drug Utilization Cost is exactly that, the cost of drugs utilized (which I break it down to different classes, antibiotic, 2B3A, Erythropoeitin, Chemo, etc and of course the Pharmacy Patient Days is calculated

Hospital Patient Days X (total rx revenue/out patient rx revenue)

This gives a clear cost of medication utilized which can be tacked monthly and annually. With strong clinical programs (driven by clinical pharmacy and GPO contracts) we can see the pharmacy financial status.

This should be incorporated into a semester class in "Healthcare System Pharmacy Management" elective.

It's dynamic. And it's an area where our expertise is beyond everyone else.

I'm little tickled that too many pharmacy students believe clinical pharmacy means they'll be practicing general medicine.

 

[ZpackSux]

My program has earnestly tried to measure CEA of pharmaceutical care and clinical pharmacy for a couple of decades now.

Truth is, if one does the math, we are overpaid for this. There is also the question of how to value a "missed" incident. It's not quite as simple as saying that when you adjust a dose, you prevent a misfill.

My systems theory prof. has said that the existence of clinical pharmacy as a viable profession is a symptom of the wrong direction for the entire health care system. If there is that much variation in the process post-hoc that a pharmacist must tend to, then the process of medication prescribing and use is not controlled well at the front end.

If you think about it, most of the work clinical pharmacy does is not preventative in nature; it is capturing aspects of care that should have been already done. For clinical pharmacy to become viable, it should not be a post-hoc measure, it should be done concurrently or prior to a patient's entry into the process.

There's a couple of things out there, Asheville, the Iowa project, but the results can be argued from increased contact rather than anything we actually could contribute.

I have to disagree about us getting overpaid for our clinical services because clinical pharmacy really should be termed "Clinical Distribution of Pharmaceuticals."

I have 6 clinical programs which will reduce my cost & utilization by close to $1,000,000 first year then maintain it. This will be done by,

Avelox/Cipro over Levaquin
Arixtra in ACS over Lovenox
Remove brand Diprivan from the formulary
Restrict, Tygacil, Cubicin, and Zyvox
Restrict Xopenex and remove Duoneb
Appropriate dosing of Erythropoeitin in Dialysis patients

It doesn't seem like much but for my little 250 Bed hospital... it's huge. And once these programs are implemented over 200 hospitals in our Corp.. imagine the possibilities and the financial impact it will have.

 

[WVUPharm2007]

I have 6 clinical programs which will reduce my cost & utilization by close to $1,000,000 first year then maintain it. This will be done by,

Avelox/Cipro over Levaquin
Arixtra in ACS over Lovenox
Remove brand Diprivan from the formulary
Restrict, Tygacil, Cubicin, and Zyvox
Restrict Xopenex and remove Duoneb
Appropriate dosing of Erythropoeitin in Dialysis patients

It doesn't seem like much but for my little 250 Bed hospital... it's huge. And once these programs are implemented over 200 hospitals in our Corp.. imagine the possibilities and the financial impact it will have.

So, basically, use common sense. If A and B have similar efficacy, but B has some advantage in a specialized case (Like Zyvox in the 1 in 1000 people with vanc resistant MRSA or whtever) with an outstanding increase in cost, then you should always use A unless the extraordinary circumstance of B occurs. If A and B have identical efficacy, but B costs more, than always use A (like Baxter-brand propofol vs Whoever-the-hell-makes-it brand Diprivan.)

Ok. To me this REALLY doesn't seem that difficult. Are physicians really this confused? Are the Xopenex reps' stupid little anti-albuterol propaganda chart really that powerful? I obviously have zero practical experience in this realm...so...uh...yeah.

 

[ZpackSux]

So, basically, use common sense. If A and B have similar efficacy, but B has some advantage in a specialized case (Like Zyvox in the 1 in 1000 people with vanc resistant MRSA or whtever) with an outstanding increase in cost, then you should always use A unless the extraordinary circumstance of B occurs. If A and B have identical efficacy, but B costs more, than always use A (like Baxter-brand propofol vs Whoever-the-hell-makes-it brand Diprivan.)

Ok. To me this REALLY doesn't seem that difficult. Are physicians really this confused? Are the Xopenex reps' stupid little anti-albuterol propaganda chart really that powerful? I obviously have zero practical experience in this realm...so...uh...yeah.

Zyvox won't help you if you have VRSA. But it will help for VRE.

You're right. The common sense approach is where it's at as long as you have enough clinical knowledge to back up your rationale. Baxter brand propofol dropped in price due to Bedford brand propofol and the brand Diprivan is made by Astra Zeneca. But in order to argue the point of why generic propofol is acceptable, you need to know that bi-sulfite preservative found in generic propofol is not the same thing as sulfur allergy caused by sulfonamide...

Yes, Xopenex reps are powerful because they wear short mini skirts and whisper sweet nothing to middle aged perverted midlife crisis driven physicians.

 

[kwizard]

So, basically, use common sense. If A and B have similar efficacy, but B has some advantage in a specialized case (Like Zyvox in the 1 in 1000 people with vanc resistant MRSA or whtever) with an outstanding increase in cost, then you should always use A unless the extraordinary circumstance of B occurs. If A and B have identical efficacy, but B costs more, than always use A (like Baxter-brand propofol vs Whoever-the-hell-makes-it brand Diprivan.)

Ok. To me this REALLY doesn't seem that difficult. Are physicians really this confused? Are the Xopenex reps' stupid little anti-albuterol propaganda chart really that powerful? I obviously have zero practical experience in this realm...so...uh...yeah.

It is not always that simple, but you are on the right track. In actual practice some things are down right obvious and other things aren't so easy to realize. As far as the influence that drug reps have on prescribing practice...priceless!! The influence of drug reps and a free meal should never be underestimated. However, determining clinical efficacy can be a pickle as you have to know how to evaluate the literature, rule out potential confounders, and conclude whether the results are applicable to your practice setting (not always so easy).

Independent of drug costs and clinical efficacy you may encounter clinical dilemmas (i.e. increased Cdiff rates w/ fluorquinolones). Is this due to to over prescribing of a particular class of antibiotics, inappropriate nursing procedures (not putting Cdiff positive pts on appropriate contact precaution protocols), or a combination of the two? The potential savings for minimizing Cdiff in a facility (especially in a long term care setting) are significant and are quickly realized similar to the previous examples mentioned by Zpack and the outcomes are fairly clearcut so the administrators won't get lost in the manner in which you calculate quality of life.

Lord999 made some interesting points, but there are some gaping holes in healthcare where pharmacists can help "patch up" which is why we are being incorporated into healthcare decision making process (i.e. rounds, more autonomy as providers, TDM) vs having to page the prescriber after the decision is already made when processing orders. Other examples are medication reconciliation, appropriate use of antibiotics, polypharmacy/med management/medication counseling especially when any of these instances results in an admission. For instance the frequent flyer who gets readmitted weekly for periods of hypoglycemia often b/c they take their insulin or other diabetic medication daily whether they eat or not or aren't familiar w/ how to measure their blood sugar. Answer to the problem...identify enough cases to justify a pharmacist to do discharge counseling if you don't have an am care pharmacist for referral. Another personal favorite would be the pt w/ Afib on digoxin who is admitted for mental status changes and no one ever figures to check a dig level for potential toxicity prior to admission. The list goes on and on, but there is a definite role for pharmacists (regardless of your training or setting) to positively impact pt care.

To SDN1977, sorry I left out the community setting, but the impact the community pharmacist can have on pt care should not be overlooked nor underappreciated as these individuals are likely to be in ideal positions to catch drug interactions and/or provide medication counseling to improve therapy (a larger percentage of the population will visit the local pharmacy more than the percentage that will be admitted to a hospital). However, given the various strains of retail I just prefer the outpt ambulatory care clinic as it tends to be a setting more optimal for dealing w/ pts and counseling as the "pure" retail setting varies from store to store.

As far as the continued evolution of clinical pharmacy, a potential gap, is that there needs to be an increasing mix of faculty paid for by the pharmacy school and w/ adjunct or clinical appointments (pd by the local hospital or community setting). Some schools are better than others, but the pharmacy school faculty often aren't as concerned w/ justifying clinical pharmacy services b/c their job doesn't depend on it b/c their job is pd by the university. The person working outside of the university has a responsibility to maintain the practice site, but fiscally supported by the hospital or retail setting so they are in the constant effort of justfying their worth clinically vs processing orders. Hence necessity is the greatest teacher.

 

[WVUPharm2007]

Zyvox won't help you if you have VRSA. But it will help for VRE.

You're right. The common sense approach is where it's at as long as you have enough clinical knowledge to back up your rationale. Baxter brand propofol dropped in price due to Bedford brand propofol and the brand Diprivan is made by Astra Zeneca. But in order to argue the point of why generic propofol is acceptable, you need to know that bi-sulfite preservative found in generic propofol is not the same thing as sulfur allergy caused by sulfonamide...

Yes, Xopenex reps are powerful because they wear short mini skirts and whisper sweet nothing to middle aged perverted midlife crisis driven physicians.

Knowledge of smartass still in school < dude with 15 years experience. You people are making me feel dumb. My experience with propofol is miniscule as I have been a retail slave all during my formidable intern years. I just remember it looked like milk and I wanted to dip oreos in it.

 

[sdn1977]

Knowledge of smartass still in school < dude with 15 years experience. You people are making me feel dumb. My experience with propofol is miniscule as I have been a retail slave all during my formidable intern years. I just remember it looked like milk and I wanted to dip oreos in it.

WVU - you crack me up ! (yeah...I know - an old phrase) You dip your oreo long enough & you won't stay awake long enough to chew (but...perhaps we could cardiovert you while you're asleep!) - just j/k!

 

[sdn1977]

If I may interject,

SDN1977, you have a "clue." Pharmacy needs more people like you and Kwizard

Zpack - thank you!! I think, however, it has more to do with experience in which we gain knowledge beyond that which is found in books.

WVU - sorry...I don't think its as simple as you described in drugs A & B. It involves not only efficacy or spectrum, but also other factors which have nothing apparently to do with the drug itself.

For example...."bundling" of medications can affect which choice of drug you allow on the formulary. Lets say drug A & B are in the same class - ciprofloxacin & levofloxacin. Drug a (ciproflox..) is cheaper if bought independently. However, the wholesaler might "bundle" the purchase of famotidine with levofloxacin. If a certain amount of famotidine is purchased, the levofloxacin is cheaper. These are unrelated drugs...but this is not an uncommon scenario...which may generate usage of an apparently more expensive drug, altho it is cheaper due to wholesaler agreements.

In my situation - when my hospital was purchased, we became one of 6 hospitals located in 3 west coast states. Our drug purchases & formulary became influenced by the contractual agreements already in place with the prior 5 hospitals. Because of this, we changed many of our formulary drugs.

Likewise...one thing which is often overlooked by pharmacists is the actual "cost" of IV tubing. Hositals, generally, do not purchase IV pumps - they are given without cost. However, the cost is recouped by the price of the tubing. If you have a drug which requires its own, dedicated tubing, or is given so frequently that another drug cannot reasonably be administered thru that tubing, you now increase your cost to the facility - usually far beyond the actual price of the drugs administered thru said tubings.

I could go on and on and on....bottom line - pharmacists need to be on the P&T committees & each medical subcommittee to provide not just pharmacologic info (which most physicians already know), but to also provide an economic perspective they have no way of knowing.

Aaaaaah - where is Caverject - I go on tooooooo long !

 

[sdn1977]

Kwizard - Since I've worked on both sides (well...three sides...) - acute, retail & outpt ambulatory care.....I've had lots of time to think about the issues of the disconnect in communication.

Do we need a new paradigm for the communication of pharmacists between outpatient (whatever the setting) & acute?

Here in CA - we do this in the prison system - go figure! When a person gets admitted...we get a call asking for the current rxs, fill history & other pertinent drugs...

I never even think about that when I see a pt in the hospital - I just use the admitting H&P, which we know is not always accurate. When I used to do discharge counseling, I would often offer to contact the pts pharmacy if we were going to d/c on an unusual medication, which I knew needing ordering. That was just courtesy - not required. This allowed me to talk to the pharmacist to explain any unusual circumstances too.

Perhaps....technology will help with this. I'm hopeful

lord999 - I do apologize, but your systems theory prof. is ignorant of clinical pharmacy. It is now & has been a viable profession for years! It occurs in all practice settings. It is not a title, nor a certain # of FTE hours - it is a mindset of how you approach your career! If he would consider healthcare as a continum of many interrelated providers (physicians, rt, pt, ot, nurses, pharmacists, etc....) it doesn't matter where any of us jump in as long as the pt ends up receiving the very best care possible. That doesn't necessarily mean the pt receives the definitive care at the outset - medicine & pharmacy is as much art as science. We don't always get the final diagnosis & treatment the first time.

 

[ZpackSux]

Knowledge of smartass still in school < dude with 15 years experience. You people are making me feel dumb. My experience with propofol is miniscule as I have been a retail slave all during my formidable intern years. I just remember it looked like milk and I wanted to dip oreos in it.

Don't feel dumb.. I was a smartass in school too...

get your ass a job at a hospital...

 

[ZpackSux]

Kwizard - Since I've worked on both sides (well...three sides...) - acute, retail & outpt ambulatory care.....I've had lots of time to think about the issues of the disconnect in communication.

Do we need a new paradigm for the communication of pharmacists between outpatient (whatever the setting) & acute?

Here in CA - we do this in the prison system - go figure! When a person gets admitted...we get a call asking for the current rxs, fill history & other pertinent drugs...

I never even think about that when I see a pt in the hospital - I just use the admitting H&P, which we know is not always accurate. When I used to do discharge counseling, I would often offer to contact the pts pharmacy if we were going to d/c on an unusual medication, which I knew needing ordering. That was just courtesy - not required. This allowed me to talk to the pharmacist to explain any unusual circumstances too.

Perhaps....technology will help with this. I'm hopeful

lord999 - I do apologize, but your systems theory prof. is ignorant of clinical pharmacy. It is now & has been a viable profession for years! It occurs in all practice settings. It is not a title, nor a certain # of FTE hours - it is a mindset of how you approach your career! If he would consider healthcare as a continum of many interrelated providers (physicians, rt, pt, ot, nurses, pharmacists, etc....) it doesn't matter where any of us jump in as long as the pt ends up receiving the very best care possible. That doesn't necessarily mean the pt receives the definitive care at the outset - medicine & pharmacy is as much art as science. We don't always get the final diagnosis & treatment the first time.

You work at the Prison? My good buddy works at the Vacaville once in a while...I hear cool stories about the lockdowns..

Actually, the communication between providers has been the biggest focus of JCAHO now...we call it the Medication Reconciliation Process.. and everyone I know are getting the dreaded RFI on it because the process is new and difficult to implement.

JCAHO medication management mandate and the National Patient Safety Goals expect us to provide the continum of care between providers as patients are transferred. Of course we compile the home med list as patients are admitted..and we're responsible for transmitting the complete medication profile to the next provider as the patient is discharged.

I'm sure this process will spill over the the outpatient pharmacy setting.

 

[ZpackSux]

If I may interject,

SDN1977, you have a "clue." Pharmacy needs more people like you and Kwizard

Zpack - thank you!! I think, however, it has more to do with experience in which we gain knowledge beyond that which is found in books.

WVU - sorry...I don't think its as simple as you described in drugs A & B. It involves not only efficacy or spectrum, but also other factors which have nothing apparently to do with the drug itself.

For example...."bundling" of medications can affect which choice of drug you allow on the formulary. Lets say drug A & B are in the same class - ciprofloxacin & levofloxacin. Drug a (ciproflox..) is cheaper if bought independently. However, the wholesaler might "bundle" the purchase of famotidine with levofloxacin. If a certain amount of famotidine is purchased, the levofloxacin is cheaper. These are unrelated drugs...but this is not an uncommon scenario...which may generate usage of an apparently more expensive drug, altho it is cheaper due to wholesaler agreements.

In my situation - when my hospital was purchased, we became one of 6 hospitals located in 3 west coast states. Our drug purchases & formulary became influenced by the contractual agreements already in place with the prior 5 hospitals. Because of this, we changed many of our formulary drugs.

Likewise...one thing which is often overlooked by pharmacists is the actual "cost" of IV tubing. Hositals, generally, do not purchase IV pumps - they are given without cost. However, the cost is recouped by the price of the tubing. If you have a drug which requires its own, dedicated tubing, or is given so frequently that another drug cannot reasonably be administered thru that tubing, you now increase your cost to the facility - usually far beyond the actual price of the drugs administered thru said tubings.

I could go on and on and on....bottom line - pharmacists need to be on the P&T committees & each medical subcommittee to provide not just pharmacologic info (which most physicians already know), but to also provide an economic perspective they have no way of knowing.

Aaaaaah - where is Caverject - I go on tooooooo long !

c'mon.. how can you talk about the bundle and not mention ole Merck's bundling of Primaxin, and Invanz and Primaxin and Pepcid...

 

[ZpackSux]

Kwizard,

What is your thought on Quinolone induced C.Diff and which Quinolone is most associated with it? As you're aware, C.Diff has been associated with every antibiotic we know.

The Canadian outbreak of the C.Diff....do we know the actual cause?

Ortho-McNeil is trying to say it was Avelox but we all know Levaquin causes PMC just as well.

My thought is that it's a multifauceted origin.

 

[sdn1977]

c'mon.. how can you talk about the bundle and not mention ole Merck's bundling of Primaxin, and Invanz and Primaxin and Pepcid...

oh gawd! yes...& more I can't begin to remembert.

And no....I don't work in a prison - it just feels like that sometimes !

 

[meg]

zpack.. what do you use to track clinical interventions? I know some programs show "soft costs" as well as the "hard costs" you're looking for. Don't know if that makes a difference.

 

[ZpackSux]

zpack.. what do you use to track clinical interventions? I know some programs show "soft costs" as well as the "hard costs" you're looking for. Don't know if that makes a difference.

Tracking clinical interventions to justify clinical pharmacy is passe'

Some people in the industry still think it is the way to go... they need to get their head out of the box.

Clinical Pharmacy Programs translates to a decrease Drug Utilization Cost per patient days in the hospital. That figure shows the trend of drug cost and to the exact penny how much money is saved by having a successful program.

 

[kwizard]

Kwizard,

What is your thought on Quinolone induced C.Diff and which Quinolone is most associated with it? As you're aware, C.Diff has been associated with every antibiotic we know.

The Canadian outbreak of the C.Diff....do we know the actual cause?

Ortho-McNeil is trying to say it was Avelox but we all know Levaquin causes PMC just as well.

My thought is that it's a multifauceted origin.

Oops, I missed this one. I agree that there appears to be a class effect given all fluoroquinolones (FQ) are ineffective against C.Difficile; however, I think the VA got "burned" when they switched from one FQ to another for formulary cost savings. I think they switched their preferred FQ from Levaquin to Tequin or Avelox and noticed an increase in Cdiff rates after the switch. Given the larger amount of anaerobic coverage w/ newer FQs this may explain some of the increased prevalence assuming other potential confounders were controlled (i.e. no other antibiotic use, equal monitoring before switch of FQs, appropriate indications for therapy, etc). There actually was a nice review in Orthapedics recently and also in one of the newsletters for Society of Infectious Disease Pharmacists.

 

[ZpackSux]

Oops, I missed this one. I agree that there appears to be a class effect given all fluoroquinolones (FQ) are ineffective against C.Difficile; however, I think the VA got "burned" when they switched from one FQ to another for formulary cost savings. I think they switched their preferred FQ from Levaquin to Tequin or Avelox and noticed an increase in Cdiff rates after the switch. Given the larger amount of anaerobic coverage w/ newer FQs this may explain some of the increased prevalence assuming other potential confounders were controlled (i.e. no other antibiotic use, equal monitoring before switch of FQs, appropriate indications for therapy, etc). There actually was a nice review in Orthapedics recently and also in one of the newsletters for Society of Infectious Disease Pharmacists.

Did VA look at the prevalent use of PPI as a source of C. Diff?

 

[kwizard]

Did VA look at the prevalent use of PPI as a source of C. Diff?

Can't remember, but good point as another indicator for increase in Cdiff rates due to decrease in gastric acidity.

 

[sdn1977]

bump

 

[SELDANE]

At the time I was working in hospital pharmacy we only had one clinical pharmacist. Like a lot of the staff pharmacists I was somewhat skeptical/curious about what she actually did. After working with her for about a week I'll have to admit she definately enlightened me and changed my opinion. She collected studies about drug dosings and then went on to help form drug protocols for our hospital. During the P&T committe meetings she was always the most well informed in the room. There's no doubt that her research and subsequent protocols (which most the physicans actually followed) saved both the hospital and its patients quite a bit of money. I find it interesting and encouraging that one of the previous posters (Zpak I think) currently has 6 clinical pharmacy programs. He must be a pharmacy director.

 

[sdn1977]

At the time I was working in hospital pharmacy we only had one clinical pharmacist. Like a lot of the staff pharmacists I was somewhat skeptical/curious about what she actually did. After working with her for about a week I'll have to admit she definately enlightened me and changed my opinion. She collected studies about drug dosings and then went on to help form drug protocols for our hospital. During the P&T committe meetings she was always the most well informed in the room. There's no doubt that her research and subsequent protocols (which most the physicans actually followed) saved both the hospital and its patients quite a bit of money. I find it interesting and encouraging that one of the previous posters (Zpak I think) currently has 6 clinical pharmacy programs. He must be a pharmacy director.

Yep - Zpak WAS a dop - he's gone on to other endeavors.

But....he hired people like me - people skilled in areas of our expertise - who could obtain & use knowledge to make a difference - whether its better drug usage or better use of our limited budgets.

A dop is a difficult position - you have to have clinical knowledge (NOT all of them do!) and an ability to interact with the bean counters & the administration.

 

[acetyl]

So I read much of this thread and I have no idea what you're talking about, but I will, and it bothers me now that I don't. Oh well.

I was wondering though, how does one come about being a bean counter?

 

[sdn1977]

So I read much of this thread and I have no idea what you're talking about, but I will, and it bothers me now that I don't. Oh well.

I was wondering though, how does one come about being a bean counter?

Get a degree in accounting, get a MHA then become a CFO of a health care facility.

(bean counter - an old term for those people who hold the purse strings!)

 

[pharmboy30]

sorry for the stupid question, but we had a new "know it all" pharmacist start today. She's had like 23 retail jobs but claims to know all about infectious disease, blah blah. She told the students today that Vancomycin does not need to be monitored because it is "sooooo purified nowadays" that there is no risk of toxicity - she said back in the day there were build up of metabolites, etc, but we don't have to worry about that at all anymore????????

huh?

 

[ZpackSux]

sorry for the stupid question, but we had a new "know it all" pharmacist start today. She's had like 23 retail jobs but claims to know all about infectious disease, blah blah. She told the students today that Vancomycin does not need to be monitored because it is "sooooo purified nowadays" that there is no risk of toxicity - she said back in the day there were build up of metabolites, etc, but we don't have to worry about that at all anymore????????

huh?

Tell her to STFU...

Monitoring of Vancomycin serves more purpose than prevention of Adverse Reactions. It is true that Vanco is purer today...in the beginning..it was called the Mississippi Mud..and accounted for a fair amount of toxicities.

But the true reason for the Vancomycin level monitoring is to ensure the level stays above the MIC. We use to shoot for the levels between 5 to 30 ug/ml years ago...now we shoot for the trough of 10 to 20ug/ml and the peak of 40ug/ml. We can predict the levels by a PK model...but nothing gives us a peace of mind like getting some levels.

Tell your know it all pharmacist let's load her and get the level up to 80ug/ml and keep it there for about 10 days... and see if she can hear.

Vanco may be pure today....but it's not without risk... very high level will result in irreversible ototoxicity.

Ask her where Tygacil could be useful and the advantages of Avelox over current quinolones on the market...and what are some common infections seen in high school athletes today and how to treat it.

What advantages are there for Primaxin over Merrem.... and what therapeutic place will the "Fifth" generation cephalosporin have in the future?

Which Echinocandin makes the best phamacoeconomic sense for a hospital today and why?

If she can't answer this stuff without missing a beat...she aint no infectious dieases guru. She shouldn't even have to think about it to answer these.

Give me a report by tomorrow.

 

[WVUPharm2007]

Ask her where Tygacil could be useful and the advantages of Avelox over current quinolones on the market...and what are some common infections seen in high school athletes today and how to treat it.
/QUOTE]

That **** cost WVU a run into the NCAA tourney last year when Mike Gansey got a nasty ass MRSA infection. Briefly killed his shot at the NBA because he was so fatigued.

 

[sdn1977]

sorry for the stupid question, but we had a new "know it all" pharmacist start today. She's had like 23 retail jobs but claims to know all about infectious disease, blah blah. She told the students today that Vancomycin does not need to be monitored because it is "sooooo purified nowadays" that there is no risk of toxicity - she said back in the day there were build up of metabolites, etc, but we don't have to worry about that at all anymore????????

huh?

I'm a bit incredulous too. Someone with 23 retail jobs (does that translate into 23 years in retail???) will have almost zip experience with the recent methodologies Zpak referred to with Vanc - or with any other antibiotic for that matter.

The big talk with Vanc for the last 5 - 10 yrs is how often we've been underdosing it & have we - ourselves - been partially responsible for the increasing resistance pattern because we've been too timid about dosing??? Pharmacists love to pontificate about how the folks in medicine have caused this issue when we carry some of the responsibiliity.

Is that who your school is using to teach you ID pharmacology, kinetics & pharmacoeconomics - someone with a background in retail??? EEEeeeek - that won't prepare you for much, I'm afraid!

 

[pharmboy30]

I'm a bit incredulous too. Someone with 23 retail jobs (does that translate into 23 years in retail???) will have almost zip experience with the recent methodologies Zpak referred to with Vanc - or with any other antibiotic for that matter.

The big talk with Vanc for the last 5 - 10 yrs is how often we've been underdosing it & have we - ourselves - been partially responsible for the increasing resistance pattern because we've been too timid about dosing??? Pharmacists love to pontificate about how the folks in medicine have caused this issue when we carry some of the responsibiliity.

Is that who your school is using to teach you ID pharmacology, kinetics & pharmacoeconomics - someone with a background in retail??? EEEeeeek - that won't prepare you for much, I'm afraid!

I've been pharmacist for 2 years...still a noob.

my first impression - she's a know-it-all with no life (large, unattractive, poor hygeine, limited social skills) who pisses people off enough that she needs to keep changing jobs. She happened to interject her "knowledge" while the third years on rotations were asking a question to another pharmacist. She got hired to work second shift with me...we are not going to get along.
The first question I asked after she left was "who the F' hired her????" I have repeatedly offered to be included in the hiring process!!!!!

she already pulled the "well, my hopsital did it this way....."