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I highly recommend this article to anyone interested in clinical pharmacy. It offers an excellent statistical analysis of the expanding roll of pharmacists as hospital clinicians. I will only post the discussion and conclusion portions of the study (the entire study is 5 pages long). Feel free to read the entire study at http://www.medscape.com/viewarticle/572663. Please note that you need to register to view the study in its entirety. And of course, there will always be a barrage of people disagreeing with this study and finding fault with it. I found it very interesting, regardless.
Discussion
Clinical Pharmacy Services
This study, as well as our previous studies,[26] documents the expansion of clinical pharmacy services over the 17 years of 19892006. For the 8 years between 1998 and 2006, 10 (71.4%) of 14 clinical pharmacy services increased, and for the 17 years between 1989 and 2006, 11 (78.6%) of the 14 clinical pharmacy services increased. In 2006, 13 (86.7%) of the 15 clinical pharmacy services (drug safety officer service was added for the 2006 survey) were more commonly provided in VA hospitals than non-VA hospitals (differences were statistically significant for eight services). It is gratifying to know that one of the largest hospital systems in the United States is consider-ably ahead of the rest of the country in providing clinical pharmacy services. Clearly, the federal government advocates and values clinical pharmacists and the services they provide to our nation's veterans.
The reasons why pharmacist participation on rounds, pharmacist-conducted clinical research, pharmacist-conducted drug histories, pharmacist-provided drug information, pharmacist-provided drug monitoring, pharmacist-provided pharmaco-kinetic consultation, and pharmacist participation on a CPR team grew at faster rates between 1998 and 2006 compared with the other clinical pharmacy services are unknown. Two factors that most likely contributed to these growth patterns were increased hospital pharmacist staffing (from a mean B1 SD of 9.67 B1 13.2 to 15.1 B1 2.3 pharmacists/100 occupied beds, an 56.2% increase) and an increase in pharmacy technicians (from 7.93 B1 12.91 to 11.8 B1 1.6 technicians/100 occupied beds, a 48.8% increase) from 1998 to 2006.[8, 25] In addition, the increased availability of doctor of pharmacy (Pharm.D.) graduates and residency-trained pharmacists during these years likely contributed to expanded clinical service. Finally, a growing body of evidence showing that clinical pharmacy services produce significant clinical and/or economic benefits for hospitalized patients has likely resulted in hospital adminis-tration support for clinical pharmacy services.[1424]
The clinical pharmacy services with the greatest percentage growth from 1989 through 2006 were pharmacist-provided drug histories, participation on rounds, drug protocol management, pharmacist-conducted clinical research, pharmacist-provided drug information, and pharmacokinetic consul-tation. In 2006, 7 (47%) of the 15 clinical pharmacy services were available in more than 50% of U.S. hospitals. In general, the growth rates for patient-specific clinical pharmacy services were greater than the growth rates for centrally delivered clinical pharmacy services, with the exceptions of drug information and clinical research.
The 300% increased growth in hospitals where pharmacists conduct drug histories from 1989 to 2006 is logical, as up to 28% of all hospital admis-sions in 1994 were attributed to drug-related morbidity and mortality.[26] In addition, a study found that 64% of physician prescribing errors occurred at the time of admission.[27] In a recent study on discrepancies in admission drugs orders in geriatric patients, the authors found that 65% of newly admitted patients had discrepancies with the drugs they were taking before admission (not documented in the chart).[28] Not only may pharmacists detect adverse drug reactions, but they obtain an accurate history of adverse drug reactions and allergies, prescription drugs, herbal medicines, and over-the-counter drugs, and they document these findings. Pharmacists, compared with other health care professionals, may be better able to detect a patient's drug-related problems. A recent study provides evidence that pharmacists obtain more accurate drug histories than do other health care professionals.[29] Table 3 shows that the service of pharmacist-provided drug histories was associated in a favorable way with six of the seven major health care outcomes we previously studied (reduced mortality rates, drug costs, length of stay, medication errors, medication errors that adversely affected patient outcomes, and adverse drug reactions).[1420, 23, 24] Some hospitals have placed pharmacists in the admissions area or emergency departments to conduct drug histories in order to meet the Joint Commission's mandate to improve drug documentation and reconciliation, to improve the efficiency of providing pharmacist-conducted drug admissions, and to improve the quality of care.[30] Given the significant favorable associations with health care outcomes and the Joint Commission's mandate, this clinical pharmacy service will likely continue to expand.
The 292.3% increase in pharmacist partici-pation on rounds between 1989 and 2006 is logical. Having a pharmacist present on rounds undoubtedly increases the likelihood that drug therapy is more appropriate. Also, substantial documentation indicates reductions in adverse drug events (66%[31] and 94%[32] reductions) when pharmacists are placed on rounds. The reasons for the accelerated growth of pharmacist presence on rounds from 1998 to 2006 are unknown but may be related to the rise of the hospitalist physician. The hospitalist physician has undoubtedly increased the opportunities for participating on rounds in many hospitals, as before the hospitalist, opportunities for participating on rounds usually only existed in teaching hospitals. Another reason for this growth may be due to the increased number of Pharm.D. graduates and residents produced from the late 1990s to 2006. One of the fundamental tenants of clinical pharmacy education and inpatient clinical training is placing students and/or residents on rounds. As such, this service probably has a large cadre of practitioners who are competent in providing clinical pharmacy services on rounds. Table 3 shows that pharmacist presence on rounds was associated in a favorable way with five of the seven major health care outcomes (reduced mortality rates, total cost of care, length of stay, medication errors that adversely affected patient outcomes, and adverse drug reactions).[1420, 23, 24] Given current growth patterns and these findings of significant benefits associated with having pharmacists participating on rounds, it is likely that this clinical pharmacy service will continue to have significant growth in the future.
The 208% increase in hospitals that had pharmacist-provided drug protocol management (collaborative drug therapy) is logical. This service is specifically designed to improve drug therapy in selected populations of patients. A 2003 ACCP White Paper on collaborative drug therapy management by pharmacists noted that 75% of the states had enacted changes in their laws or practice acts to increase the pharmacist's role in the management of patients' drug therapy.[33] Of the 154 single-site studies involving pharmacist collaborative drug therapy manage-ment, 85% showed beneficial results on patient care outcomes.[33] Previous large-scale studies on pharmacist-provided drug therapy management under protocols found that hospitals that did not have pharmacist-provided drug management had the following increases in deaths for the given drug: heparin, 4664 more deaths; warfarin, 2786 more deaths; aminoglycoside or vancomycin, 1048 more deaths; epileptic drug, 374 more deaths; and antibiotic prophylaxis in surgery, 105 more deaths.[23, 24, 34, 35] In these studies, however, with pharmacist-provided drug protocol manage-ment, substantial reductions were noted in length of stay, total cost of care, drug costs, laboratory costs, and complications.[23, 24, 34, 35] Also, in hospitals that had these services, pharmacists managed a mean B1 SD of 4.19 B1 3.42 drugs under protocol in 1998 and 9.18 B1 10.23 drugs in 2006 (a 119.1% increase). These findings indicate that this clinical pharmacy service has not only grown substantially in our nation's hospitals, but once it is started, the number of drugs managed under protocol also grows. Table 3 shows that pharmacist-managed drug therapy under protocols was associated in a favorable way with all seven of the major health care outcomes we have previously studied.[1420] Pharmacist-managed drug therapy under protocol is one of only three variables that were associated in a favorable way with all seven of these health care outcomes.[1420] Although there is not much room for this clinical pharmacy service to grow (76.8% of U.S. hospitals already provide this service), it is likely that the number of drugs managed by pharmacists will grow in the future.
The reasons for a 166.7% increase in hospitals that have pharmacists conducting clinical research from 19892006 are unknown. Perhaps the funding and increased prestige that a hospital may experience with published works are the reasons for the growth of clinical research in the discipline. Another reason may be that Pharm.D. programs have increased course work devoted to statistics and study design compared with the bachelor of science in pharmacy degree programs and, thus, produce graduates with greater research capabilities. In addition, residency programs usually contain a research project, which may further enhance research skills.
An alternative reason for the growth in clinical research may be due to the significant growth of clinical pharmacy services in general. The significant growth in clinical pharmacy services is likely accompanied by documentation of improved clinical and/or economic outcomes for these services. As such, pharmacists probably have developed better research skills through their successful documentation efforts, which may lead to other creative endeavors. Although this service was associated with only one major health care outcome ( Table 3 ), its growth over the 17 years clearly demonstrates the importance attached to scholarship in our nation's hospitals. This clinical pharmacy service is very important for future development of our profession, as well as the maturation of clinical pharmacy as a discipline, since it provides the engine for future growth of services and the successful documen-tation of beneficial clinical and economic outcomes.
The 150% increase in growth in pharmacist-provided drug information from 19892006 is logical. Pharmacist-provided drug information is likely the first clinical pharmacy service that developed in our nation's hospitals and serves as one of the basic clinical pharmacy services provided by all clinical pharmacists, irrespective of location or function. Table 3 shows this service was associated with four major health care outcomes (reduced drug costs, total cost of care, medication errors, and mortality rate).[1420, 23, 24] The drug information center has changed over the years from simply providing drug information to more of a health care policy center where the pharmacist manages the formulary, tracks and reports adverse drug reactions and medication errors, and directly promotes improved drug therapy (often through evidence-based protocols). Whether this clinical pharmacy service will continue to grow in the future is unknown. With the changes that have occurred in drug informatics over the past 510 years (extensive drug information sources are now available to any pharmacist with a laptop computer or personal digital assistant), the traditional role of the drug information pharmacist has changed and will continue to evolve.
The 117.5% increase in pharmacist-provided pharmacokinetic consultation from 19892006 is logical. This clinical pharmacy service was one of the first patient-specific clinical pharmacy services provided in many hospitals. Even though this service was not associated with any of our major health care outcomes in Table 3 , it nevertheless is a functional responsibility of many hospital pharmacists.[14-20, 23, 24] The lack of associations could easily be explained as change from a stand-alone independent clinical service to an integrated clinical function for decen-tralized pharmacists. Given the changes in Pharm.D. programs from 1970 to the 1990s, where emphasis on basic and clinical pharmaco-kinetics increased, most graduates now have the ability to perform pharmacokinetic calculations, and the need for freestanding consult services has probably diminished. Alternatively, the clinical service may have transformed into drug protocol management (which was associated with all seven major health care outcomes).[1420, 23, 24] Since pharmacist-provided pharmacokinetic consultation is already present in 86.8% of hospitals, little future growth is expected.
Several other services have increased substan-tially since 1989: pharmacist-provided drug counseling, adverse drug reaction management, participation on a total parenteral nutrition team, and drug therapy monitoring. Given space limitations, a detailed discussion of these clinical pharmacy services will not be provided.
The one new clinical pharmacy service queried was the presence of a pharmacist drug safety officer, which was present in 35.2% of hospitals. However, it is not surprising that a little more than one third of U.S. hospitals have a pharmacist drug safety officer, since the Institute of Medicine has highlighted patient safety concerns over the past decade.[36, 37] These data, as well as data in our previous articles, clearly point to expansion of clinical pharmacy services in our nation's hospitals.[26, 1420, 23, 24] Although the past is not necessarily a prediction of the future, past growth patterns suggest a very bright future for clinical pharmacy.
As previously stated, a core set of clinical pharmacy services should be considered for all patients; these services should have at least three favorable associations with major health care outcomes. Our 2006 data indicate the following are core clinical pharmacy services: pharmacist-provided in-service education (three favorable associations), pharmacist-provided adverse drug reaction management (four favorable associa-tions), pharmacist-provided drug information (four favorable associations), medical rounds participation (five favorable associations), pharmacist-provided drug histories (six favorable associations), and pharmacist-provided drug protocol management (seven favorable associa-tions).[1420] In addition, increased clinical pharmacist staffing/occupied bed and decentralized pharmacists were associated with all seven major health care outcomes in a favorable way. It is interesting to note that two variables considered unfavorable were centralized pharmacy location and increased staffing of dispensing pharmacists/ occupied bed, with three unfavorable associations each ( Table 3 ).
The recently enacted rules that allow techni-cians to check technician dispensing functions without pharmacist dispensing oversight in California hospitals may become a future trend in the profession.[38] These changes were based on study results indicating that technicians make fewer dispensing errors and that pharmacists need to expand their clinical functions.[38] Minnesota also adopted similar technician-checking-tech-nician rules.[39] Hospital pharmacy directors and clinical coordinators may want to consider the list of core clinical pharmacy services, clinical pharmacist staffing, and decentralized pharmacists when they allocate resources to care for their patients.
Drug Protocol Management
The only two drugs that were managed under protocol in greater than 50% of U.S. hospitals were aminoglycosides (64.4%) and vancomycin (63.8%). These findings are not surprising as we have previously shown that in hospitals that did not have pharmacist-provided aminoglycoside or vancomycin management, death rates were 6.71% higher (1048 excess deaths), length of stay was 10.94% longer (131,660 excess patient days), total Medicare charges were 6.30% higher ($140,745,924 in excess total Medicare charges), drug charges were 8.15% higher ($34,769,250 in excess drug charges), laboratory charges were 7.80% higher ($22,530,474 in excess laboratory charges), hearing loss was 46.42% higher (134 more patients with hearing loss), renal impair-ment was 33.95% higher (2801 more patients with renal impairment), and the death rate in patients who developed complications was 10.15% higher (231 excess deaths, p<0.0001).[24] Other authors have also documented the benefits of having pharmacists manage these drugs.[4047]
It is also not surprising that four classes of anticoagulants were on the list in Table 2 , as we have previously shown that in hospitals without pharmacist-provided heparin management, death rates were 11.41% higher, length of stay was 10.05% longer, total charges were 6.60% higher, bleeding complications were 3.1% higher, and transfusion rate (for bleeding complications) was 5.47% higher.[23] In hospitals without pharmacist-provided warfarin management, death rates were 6.20% higher, length of stay was 5.86% longer, total charges were 2.16% higher, bleeding complication rates were 8.09% higher, and transfusion rate (for bleeding complications) was 22.49% higher.[23] Other authors have also reported similar findings.[4858] It is likely that pharmacist-managed anticoagulation services will expand as the Joint Commission's patient safety goals for anticoagulation are implemented in our nation's hospitals.[59]
Based on the literature, we would not have expected drugs like the antiparkinsonian agents, erythopoiesis stimulants, proton pump inhibitors, and histamine2 blockers to be commonly managed by pharmacists in U.S. hospitals. Likewise, the lack of cardiovascular agents, statins, antiplatelet agents, oral antidiabetic agents, antihypertensives, bisphosphonates, and asthma drugs in Table 2 was somewhat surprising. In many ways, there appears to be a fundamental disconnect between the drugs that pharmacists manage in hospitals and those that are managed in ambulatory care settings. These findings suggest that we may want to focus on improving the continuum of care between the hospital and ambulatory settings by better coordinating and managing the same drugs in both hospital and ambulatory patient populations.
Medication Errors
The 328,879 medication errors reported in the study rank it as the largest study ever reported on medication errors collected over a 1-year period. The mean number of medication errors/hospital increased by 151.4% between 1995 and 2006 ( Table 4 ).[5, 6] The percentage of patients who experienced a medication error increased from 4.7% to 6.5% between 1995 through 2006 (a 38.3% increase).[5, 6] Although there was a substantial increase in reported medication errors reported between 1995 and 2006, this may not actually reflect a decline in patient safety as it may reflect better reporting systems. Given the Institute of Medicine's publications on patient safety, as well as other publicity in both lay and professional publications, these findings may be due to improved reporting mechanisms, rather than any significant deterioration in patient safety in our nation's hospitals.[36, 37] Pharmacist-provided drug information, adverse drug reaction management, drug protocol management, drug admission histories, increased clinical pharmacist staffing, and decentralized pharmacists were all associated with reduced medication errors ( Table 3 ). The United States Pharmacopeia MEDMARX programs found that 3% of medication errors actually caused harm.[60] This finding would result in actual patient harm to 9866 patients or 19.08 patients/hospital/year in the 517 hospitals that reported information on medication errors.
Pharmacy Technology
A total of 220 hospitals (19.6%) had computerized prescriber order entry systems, 263 (23.4%) had bar coding for drug administration, and 439 (39%) used robotics for dispensing. Although we have no previous data to compare these findings to indicate growth, it appears that hospitals are increasing the utilization of drug delivery system technology based on previous reports.[61, 62] Given these trends, it is likely that we will continue to see a trend toward more clinical pharmacy services provided by pharmacists and less emphasis being placed on dispensing and drug delivery by pharmacists.
These findings clearly support the expansion of clinical pharmacy services in our nation's hospitals. Generally, the most dramatic growth patterns were seen with patient-specific services rather than centrally delivered clinical pharmacy services between 1989 and 2006. Overall, these results provide good news for our discipline and for our patients.
Limitations
Data were obtained from acute care general medicalsurgical hospitals and pediatric hospitals and should not be extrapolated to other types of hospitals. As with any self-reported data, there can be no absolute assurance that the data are correct. It is possible that the information provided to us was inaccurate. We did not attempt to verify information by phone contact or through hospital visitation. It is possible that the hospitals in our study population were not representative of all U.S. hospitals. However, this is doubtful since the 1125 study hospitals had 14,315,506 hospital admissions, which represent 45.7% of all 31,324,496 U.S. hospital admissions.[13] The response rate was an acceptable 38.9%, but the possibility of nonresponder bias remains. Again, this is doubtful due to the size of the study popu-lation and the percentage of total U.S. hospital admissions included in the study. Definitions of clinical pharmacy services, which we have used or refined over the past 17 years, were crafted carefully to limit variation in interpretation; however, interpretation still may have varied.
Discussion
Clinical Pharmacy Services
This study, as well as our previous studies,[26] documents the expansion of clinical pharmacy services over the 17 years of 19892006. For the 8 years between 1998 and 2006, 10 (71.4%) of 14 clinical pharmacy services increased, and for the 17 years between 1989 and 2006, 11 (78.6%) of the 14 clinical pharmacy services increased. In 2006, 13 (86.7%) of the 15 clinical pharmacy services (drug safety officer service was added for the 2006 survey) were more commonly provided in VA hospitals than non-VA hospitals (differences were statistically significant for eight services). It is gratifying to know that one of the largest hospital systems in the United States is consider-ably ahead of the rest of the country in providing clinical pharmacy services. Clearly, the federal government advocates and values clinical pharmacists and the services they provide to our nation's veterans.
The reasons why pharmacist participation on rounds, pharmacist-conducted clinical research, pharmacist-conducted drug histories, pharmacist-provided drug information, pharmacist-provided drug monitoring, pharmacist-provided pharmaco-kinetic consultation, and pharmacist participation on a CPR team grew at faster rates between 1998 and 2006 compared with the other clinical pharmacy services are unknown. Two factors that most likely contributed to these growth patterns were increased hospital pharmacist staffing (from a mean B1 SD of 9.67 B1 13.2 to 15.1 B1 2.3 pharmacists/100 occupied beds, an 56.2% increase) and an increase in pharmacy technicians (from 7.93 B1 12.91 to 11.8 B1 1.6 technicians/100 occupied beds, a 48.8% increase) from 1998 to 2006.[8, 25] In addition, the increased availability of doctor of pharmacy (Pharm.D.) graduates and residency-trained pharmacists during these years likely contributed to expanded clinical service. Finally, a growing body of evidence showing that clinical pharmacy services produce significant clinical and/or economic benefits for hospitalized patients has likely resulted in hospital adminis-tration support for clinical pharmacy services.[1424]
The clinical pharmacy services with the greatest percentage growth from 1989 through 2006 were pharmacist-provided drug histories, participation on rounds, drug protocol management, pharmacist-conducted clinical research, pharmacist-provided drug information, and pharmacokinetic consul-tation. In 2006, 7 (47%) of the 15 clinical pharmacy services were available in more than 50% of U.S. hospitals. In general, the growth rates for patient-specific clinical pharmacy services were greater than the growth rates for centrally delivered clinical pharmacy services, with the exceptions of drug information and clinical research.
The 300% increased growth in hospitals where pharmacists conduct drug histories from 1989 to 2006 is logical, as up to 28% of all hospital admis-sions in 1994 were attributed to drug-related morbidity and mortality.[26] In addition, a study found that 64% of physician prescribing errors occurred at the time of admission.[27] In a recent study on discrepancies in admission drugs orders in geriatric patients, the authors found that 65% of newly admitted patients had discrepancies with the drugs they were taking before admission (not documented in the chart).[28] Not only may pharmacists detect adverse drug reactions, but they obtain an accurate history of adverse drug reactions and allergies, prescription drugs, herbal medicines, and over-the-counter drugs, and they document these findings. Pharmacists, compared with other health care professionals, may be better able to detect a patient's drug-related problems. A recent study provides evidence that pharmacists obtain more accurate drug histories than do other health care professionals.[29] Table 3 shows that the service of pharmacist-provided drug histories was associated in a favorable way with six of the seven major health care outcomes we previously studied (reduced mortality rates, drug costs, length of stay, medication errors, medication errors that adversely affected patient outcomes, and adverse drug reactions).[1420, 23, 24] Some hospitals have placed pharmacists in the admissions area or emergency departments to conduct drug histories in order to meet the Joint Commission's mandate to improve drug documentation and reconciliation, to improve the efficiency of providing pharmacist-conducted drug admissions, and to improve the quality of care.[30] Given the significant favorable associations with health care outcomes and the Joint Commission's mandate, this clinical pharmacy service will likely continue to expand.
The 292.3% increase in pharmacist partici-pation on rounds between 1989 and 2006 is logical. Having a pharmacist present on rounds undoubtedly increases the likelihood that drug therapy is more appropriate. Also, substantial documentation indicates reductions in adverse drug events (66%[31] and 94%[32] reductions) when pharmacists are placed on rounds. The reasons for the accelerated growth of pharmacist presence on rounds from 1998 to 2006 are unknown but may be related to the rise of the hospitalist physician. The hospitalist physician has undoubtedly increased the opportunities for participating on rounds in many hospitals, as before the hospitalist, opportunities for participating on rounds usually only existed in teaching hospitals. Another reason for this growth may be due to the increased number of Pharm.D. graduates and residents produced from the late 1990s to 2006. One of the fundamental tenants of clinical pharmacy education and inpatient clinical training is placing students and/or residents on rounds. As such, this service probably has a large cadre of practitioners who are competent in providing clinical pharmacy services on rounds. Table 3 shows that pharmacist presence on rounds was associated in a favorable way with five of the seven major health care outcomes (reduced mortality rates, total cost of care, length of stay, medication errors that adversely affected patient outcomes, and adverse drug reactions).[1420, 23, 24] Given current growth patterns and these findings of significant benefits associated with having pharmacists participating on rounds, it is likely that this clinical pharmacy service will continue to have significant growth in the future.
The 208% increase in hospitals that had pharmacist-provided drug protocol management (collaborative drug therapy) is logical. This service is specifically designed to improve drug therapy in selected populations of patients. A 2003 ACCP White Paper on collaborative drug therapy management by pharmacists noted that 75% of the states had enacted changes in their laws or practice acts to increase the pharmacist's role in the management of patients' drug therapy.[33] Of the 154 single-site studies involving pharmacist collaborative drug therapy manage-ment, 85% showed beneficial results on patient care outcomes.[33] Previous large-scale studies on pharmacist-provided drug therapy management under protocols found that hospitals that did not have pharmacist-provided drug management had the following increases in deaths for the given drug: heparin, 4664 more deaths; warfarin, 2786 more deaths; aminoglycoside or vancomycin, 1048 more deaths; epileptic drug, 374 more deaths; and antibiotic prophylaxis in surgery, 105 more deaths.[23, 24, 34, 35] In these studies, however, with pharmacist-provided drug protocol manage-ment, substantial reductions were noted in length of stay, total cost of care, drug costs, laboratory costs, and complications.[23, 24, 34, 35] Also, in hospitals that had these services, pharmacists managed a mean B1 SD of 4.19 B1 3.42 drugs under protocol in 1998 and 9.18 B1 10.23 drugs in 2006 (a 119.1% increase). These findings indicate that this clinical pharmacy service has not only grown substantially in our nation's hospitals, but once it is started, the number of drugs managed under protocol also grows. Table 3 shows that pharmacist-managed drug therapy under protocols was associated in a favorable way with all seven of the major health care outcomes we have previously studied.[1420] Pharmacist-managed drug therapy under protocol is one of only three variables that were associated in a favorable way with all seven of these health care outcomes.[1420] Although there is not much room for this clinical pharmacy service to grow (76.8% of U.S. hospitals already provide this service), it is likely that the number of drugs managed by pharmacists will grow in the future.
The reasons for a 166.7% increase in hospitals that have pharmacists conducting clinical research from 19892006 are unknown. Perhaps the funding and increased prestige that a hospital may experience with published works are the reasons for the growth of clinical research in the discipline. Another reason may be that Pharm.D. programs have increased course work devoted to statistics and study design compared with the bachelor of science in pharmacy degree programs and, thus, produce graduates with greater research capabilities. In addition, residency programs usually contain a research project, which may further enhance research skills.
An alternative reason for the growth in clinical research may be due to the significant growth of clinical pharmacy services in general. The significant growth in clinical pharmacy services is likely accompanied by documentation of improved clinical and/or economic outcomes for these services. As such, pharmacists probably have developed better research skills through their successful documentation efforts, which may lead to other creative endeavors. Although this service was associated with only one major health care outcome ( Table 3 ), its growth over the 17 years clearly demonstrates the importance attached to scholarship in our nation's hospitals. This clinical pharmacy service is very important for future development of our profession, as well as the maturation of clinical pharmacy as a discipline, since it provides the engine for future growth of services and the successful documen-tation of beneficial clinical and economic outcomes.
The 150% increase in growth in pharmacist-provided drug information from 19892006 is logical. Pharmacist-provided drug information is likely the first clinical pharmacy service that developed in our nation's hospitals and serves as one of the basic clinical pharmacy services provided by all clinical pharmacists, irrespective of location or function. Table 3 shows this service was associated with four major health care outcomes (reduced drug costs, total cost of care, medication errors, and mortality rate).[1420, 23, 24] The drug information center has changed over the years from simply providing drug information to more of a health care policy center where the pharmacist manages the formulary, tracks and reports adverse drug reactions and medication errors, and directly promotes improved drug therapy (often through evidence-based protocols). Whether this clinical pharmacy service will continue to grow in the future is unknown. With the changes that have occurred in drug informatics over the past 510 years (extensive drug information sources are now available to any pharmacist with a laptop computer or personal digital assistant), the traditional role of the drug information pharmacist has changed and will continue to evolve.
The 117.5% increase in pharmacist-provided pharmacokinetic consultation from 19892006 is logical. This clinical pharmacy service was one of the first patient-specific clinical pharmacy services provided in many hospitals. Even though this service was not associated with any of our major health care outcomes in Table 3 , it nevertheless is a functional responsibility of many hospital pharmacists.[14-20, 23, 24] The lack of associations could easily be explained as change from a stand-alone independent clinical service to an integrated clinical function for decen-tralized pharmacists. Given the changes in Pharm.D. programs from 1970 to the 1990s, where emphasis on basic and clinical pharmaco-kinetics increased, most graduates now have the ability to perform pharmacokinetic calculations, and the need for freestanding consult services has probably diminished. Alternatively, the clinical service may have transformed into drug protocol management (which was associated with all seven major health care outcomes).[1420, 23, 24] Since pharmacist-provided pharmacokinetic consultation is already present in 86.8% of hospitals, little future growth is expected.
Several other services have increased substan-tially since 1989: pharmacist-provided drug counseling, adverse drug reaction management, participation on a total parenteral nutrition team, and drug therapy monitoring. Given space limitations, a detailed discussion of these clinical pharmacy services will not be provided.
The one new clinical pharmacy service queried was the presence of a pharmacist drug safety officer, which was present in 35.2% of hospitals. However, it is not surprising that a little more than one third of U.S. hospitals have a pharmacist drug safety officer, since the Institute of Medicine has highlighted patient safety concerns over the past decade.[36, 37] These data, as well as data in our previous articles, clearly point to expansion of clinical pharmacy services in our nation's hospitals.[26, 1420, 23, 24] Although the past is not necessarily a prediction of the future, past growth patterns suggest a very bright future for clinical pharmacy.
As previously stated, a core set of clinical pharmacy services should be considered for all patients; these services should have at least three favorable associations with major health care outcomes. Our 2006 data indicate the following are core clinical pharmacy services: pharmacist-provided in-service education (three favorable associations), pharmacist-provided adverse drug reaction management (four favorable associa-tions), pharmacist-provided drug information (four favorable associations), medical rounds participation (five favorable associations), pharmacist-provided drug histories (six favorable associations), and pharmacist-provided drug protocol management (seven favorable associa-tions).[1420] In addition, increased clinical pharmacist staffing/occupied bed and decentralized pharmacists were associated with all seven major health care outcomes in a favorable way. It is interesting to note that two variables considered unfavorable were centralized pharmacy location and increased staffing of dispensing pharmacists/ occupied bed, with three unfavorable associations each ( Table 3 ).
The recently enacted rules that allow techni-cians to check technician dispensing functions without pharmacist dispensing oversight in California hospitals may become a future trend in the profession.[38] These changes were based on study results indicating that technicians make fewer dispensing errors and that pharmacists need to expand their clinical functions.[38] Minnesota also adopted similar technician-checking-tech-nician rules.[39] Hospital pharmacy directors and clinical coordinators may want to consider the list of core clinical pharmacy services, clinical pharmacist staffing, and decentralized pharmacists when they allocate resources to care for their patients.
Drug Protocol Management
The only two drugs that were managed under protocol in greater than 50% of U.S. hospitals were aminoglycosides (64.4%) and vancomycin (63.8%). These findings are not surprising as we have previously shown that in hospitals that did not have pharmacist-provided aminoglycoside or vancomycin management, death rates were 6.71% higher (1048 excess deaths), length of stay was 10.94% longer (131,660 excess patient days), total Medicare charges were 6.30% higher ($140,745,924 in excess total Medicare charges), drug charges were 8.15% higher ($34,769,250 in excess drug charges), laboratory charges were 7.80% higher ($22,530,474 in excess laboratory charges), hearing loss was 46.42% higher (134 more patients with hearing loss), renal impair-ment was 33.95% higher (2801 more patients with renal impairment), and the death rate in patients who developed complications was 10.15% higher (231 excess deaths, p<0.0001).[24] Other authors have also documented the benefits of having pharmacists manage these drugs.[4047]
It is also not surprising that four classes of anticoagulants were on the list in Table 2 , as we have previously shown that in hospitals without pharmacist-provided heparin management, death rates were 11.41% higher, length of stay was 10.05% longer, total charges were 6.60% higher, bleeding complications were 3.1% higher, and transfusion rate (for bleeding complications) was 5.47% higher.[23] In hospitals without pharmacist-provided warfarin management, death rates were 6.20% higher, length of stay was 5.86% longer, total charges were 2.16% higher, bleeding complication rates were 8.09% higher, and transfusion rate (for bleeding complications) was 22.49% higher.[23] Other authors have also reported similar findings.[4858] It is likely that pharmacist-managed anticoagulation services will expand as the Joint Commission's patient safety goals for anticoagulation are implemented in our nation's hospitals.[59]
Based on the literature, we would not have expected drugs like the antiparkinsonian agents, erythopoiesis stimulants, proton pump inhibitors, and histamine2 blockers to be commonly managed by pharmacists in U.S. hospitals. Likewise, the lack of cardiovascular agents, statins, antiplatelet agents, oral antidiabetic agents, antihypertensives, bisphosphonates, and asthma drugs in Table 2 was somewhat surprising. In many ways, there appears to be a fundamental disconnect between the drugs that pharmacists manage in hospitals and those that are managed in ambulatory care settings. These findings suggest that we may want to focus on improving the continuum of care between the hospital and ambulatory settings by better coordinating and managing the same drugs in both hospital and ambulatory patient populations.
Medication Errors
The 328,879 medication errors reported in the study rank it as the largest study ever reported on medication errors collected over a 1-year period. The mean number of medication errors/hospital increased by 151.4% between 1995 and 2006 ( Table 4 ).[5, 6] The percentage of patients who experienced a medication error increased from 4.7% to 6.5% between 1995 through 2006 (a 38.3% increase).[5, 6] Although there was a substantial increase in reported medication errors reported between 1995 and 2006, this may not actually reflect a decline in patient safety as it may reflect better reporting systems. Given the Institute of Medicine's publications on patient safety, as well as other publicity in both lay and professional publications, these findings may be due to improved reporting mechanisms, rather than any significant deterioration in patient safety in our nation's hospitals.[36, 37] Pharmacist-provided drug information, adverse drug reaction management, drug protocol management, drug admission histories, increased clinical pharmacist staffing, and decentralized pharmacists were all associated with reduced medication errors ( Table 3 ). The United States Pharmacopeia MEDMARX programs found that 3% of medication errors actually caused harm.[60] This finding would result in actual patient harm to 9866 patients or 19.08 patients/hospital/year in the 517 hospitals that reported information on medication errors.
Pharmacy Technology
A total of 220 hospitals (19.6%) had computerized prescriber order entry systems, 263 (23.4%) had bar coding for drug administration, and 439 (39%) used robotics for dispensing. Although we have no previous data to compare these findings to indicate growth, it appears that hospitals are increasing the utilization of drug delivery system technology based on previous reports.[61, 62] Given these trends, it is likely that we will continue to see a trend toward more clinical pharmacy services provided by pharmacists and less emphasis being placed on dispensing and drug delivery by pharmacists.
These findings clearly support the expansion of clinical pharmacy services in our nation's hospitals. Generally, the most dramatic growth patterns were seen with patient-specific services rather than centrally delivered clinical pharmacy services between 1989 and 2006. Overall, these results provide good news for our discipline and for our patients.
Limitations
Data were obtained from acute care general medicalsurgical hospitals and pediatric hospitals and should not be extrapolated to other types of hospitals. As with any self-reported data, there can be no absolute assurance that the data are correct. It is possible that the information provided to us was inaccurate. We did not attempt to verify information by phone contact or through hospital visitation. It is possible that the hospitals in our study population were not representative of all U.S. hospitals. However, this is doubtful since the 1125 study hospitals had 14,315,506 hospital admissions, which represent 45.7% of all 31,324,496 U.S. hospital admissions.[13] The response rate was an acceptable 38.9%, but the possibility of nonresponder bias remains. Again, this is doubtful due to the size of the study popu-lation and the percentage of total U.S. hospital admissions included in the study. Definitions of clinical pharmacy services, which we have used or refined over the past 17 years, were crafted carefully to limit variation in interpretation; however, interpretation still may have varied.
