Health Articles

Hospital pharmacists are responsible for acquiring, storing, and distributing medicines and other pharmaceutical preparations. They also participate in the drug utilization review process, serve on pharmacy and therapeutics committees, and often join physicians on clinical rounds. The pharmacist’s expertise may be particularly valuable to older patients since age-related changes in pharmacokinetics and tissue sensitivity may be amplified by drugs commonly used to treat acute diseases (eg, antibiotics, antiarrhythmics, anticoagulants, thrombolytic agents).
Many hospital pharmacies provide a number of programs, including comprehensive drug information centers, pharmacokinetic dosing advice to physicians, and nutrition support services. In addition, pharmacists may serve on multidisciplinary teams. For example, as a member of a geriatric assessment unit, the pharmacist obtains a patient’s medication history that includes patterns of use for all drug regimens, therapeutic effectiveness, duplication of drugs, adverse drug reactions, and drug interactions. The pharmacist then makes recommendations to optimize drug use (eg, counseling and teaching the patient and family, recommending alternative therapy, or adjusting the current regimen). Similar activities are conducted in hospital-based geriatrics clinics and in community-outreach programs in which patients are seen in satellite clinics, in congregate housing facilities, or at home.
Pharmacists are responsible for dispensing discharge medications and for instructing patients and their caregivers on proper use of these medications. Nurses, who can help establish the most effective means of communicating vital information, should be involved in such instruction. For most elderly patients, instructions for medication use after discharge should be written.

Since 1965, federal regulations have issued specific mandates for pharmacy services in nursing homes and other long-term care facilities. To meet requirements for Medicare and Medicaid reimbursement, pharmacists must conduct monthly drug regimen reviews, in which they reevaluate a patient’s drug regimen and make appropriate recommendations to the patient’s physician. Drug regimen reviews help to decrease polypharmacy, minimize duplication of drugs, prevent significant drug interactions, and reduce the inappropriate or unnecessary use of drugs. The Health Care Financing Administration has established guidelines for use by surveyors in assessing a facility’s drug regimen review process (see TABLE 22-2). This list of apparent irregularities reflects problems that have been seen in long-term care facilities. Other duties of the pharmacist in a long-term care facility include managing the labeling, storage, and security and inventory control of drugs; reporting irregularities in drug regimens to the administration, the director of nursing, and the primary physician for appropriate action; and implementing guidelines for reducing unnecessary drug therapy, particularly psychoactive drugs. The Health Care Financing Administration defines unnecessary drug therapy as the use of any drug in excessive dose, for excessive duration, without adequate monitoring, without adequate indication for its use, or when circumstances indicate that the dose should be reduced or the drug discontinued. One goal of the Omnibus Budget Reconciliation Act of 1987 (OBRA 87) was to reduce the use of antipsychotic drugs as chemical restraints.

Many disabled elderly persons are cared for at home by family members. In addition, over 9000 agencies are certified to provide services at home to Medicare beneficiaries. Home health care agencies accredited by the Joint Commission on Accreditation of Healthcare Organizations must contract for pharmacy services. The pharmacist is required not only to dispense and deliver medications but also to continually monitor the use of drugs by patients cared for at home. The pharmacist should be able to manage the administration of IV fluids such as total parenteral nutrition and other therapies such as anticoagulation, cancer chemotherapy, and inhalation therapy

Traditionally, the community pharmacist has dispensed prescriptions, provided informal advice and counseling (particularly on over-the-counter drugs), referred patients to physicians, and conferred with physicians on drug therapy.
Advances in computer technology have enhanced the counseling role of the community pharmacist (see TABLE 22-1). Most pharmacies use computers to keep patient records, including medication profiles. The medication profile can help identify duplication of drugs, overuse and underuse, allergies, drug interactions, potential adverse reactions, and special counseling needs of individual patients. However, most such programs do not have criteria specific to the elderly. Some computer programs specify when a patient is scheduled for a medication refill or a return visit to the physician. This information enables the pharmacist to identify noncompliance and to counsel the patient more effectively. Because the elderly purchase many over-the-counter drugs (especially analgesics, cough and cold preparations, vitamins, antacids, and laxatives), pharmacist counseling and monitoring of such drug use can decrease the potential for adverse reactions or drug interactions.

The settings in which pharmacy services are provided include community pharmacies, home health care programs, long-term care facilities, and hospitals. Of the nation’s 190,000 licensed pharmacists, 112,000 practice in chain store or independent community pharmacies; 40,000 in hospital pharmacies; and 21,000 in consultation, academia, industry, or government.

The Health Care Financing Administration defines drug utilization review as “a structured, ongoing, quality assurance process to ensure that drugs are prescribed and dispensed appropriately, safely, effectively, and economically.”
Drug utilization review (DUR) programs are directed and staffed mainly by pharmacists. The Omnibus Budget Reconciliation Act of 1990 (OBRA 90), which became effective in January 1993, requires that all states establish DUR programs in hospitals and long-term care facilities for drugs reimbursed through Medicaid. Health maintenance organizations and similar organizations, Veterans Administration hospitals, and state programs providing drug services also use DUR programs extensively. A demonstration project was initiated in 1993 to validate the application of DUR at the pharmacy level.
Drug utilization review programs have prospective, concurrent, and retrospective components. Prospective DUR is done at the point of sale (ie, the pharmacy) before the patient gets the drug. Pharmacists are required to obtain and record certain information about patients and their drug prescriptions; this information enables the pharmacist to assess the appropriateness of a particular prescription before dispensing it. The pharmacist may collaborate with the prescribing physician to resolve potential problems. Pharmacists must also counsel patients before filling prescriptions covered by Medicaid, with the aim of improving compliance and avoiding medication errors.
Concurrent DUR programs evaluate the use of drugs currently being prescribed. Information on potentially problematic drug use is supplied to prescribers to allow them to adjust therapy before it harms the patient. Concurrent DUR can also be used to control costs.
In retrospective DUR, data on aggregate drug use in a health care setting are collected and evaluated to identify trends, overuse and underuse, adverse drug reactions, and drug interactions and to analyze expenditures. In some programs, the appropriateness of prescribing patterns can be assessed by linking drugs to diagnoses. Strategies are developed to correct abuses and inappropriate practices, and corrective actions are transmitted to the prescribers.

The Role of The Pharmacist
Advances in health care technology and changes in federal regulations have given increasing importance to the pharmacist’s role on the health care team. Besides dispensing drugs, pharmacists collaborate with physicians and counsel patients. Since drug use increases with age (the elderly consume > 30% of all prescription drugs and about 40% of over-the-counter drugs), the pharmacist’s expertise is especially important to the elderly.
Pharmacists, as well as physicians, must be aware of the implications of altered pharmacodynamics and pharmacokinetics in elderly patients (see Ch. 21). They should also recognize that the elderly have a high incidence of adverse drug reactions and interactions, poor compliance with drug regimens, and overuse and underuse of drugs. In consultation with the physician, the pharmacist can help avoid or resolve these problems by recommending appropriate or alternative drugs and by advising and monitoring patients, especially concerning compliance.
To meet the need for pharmacists with expertise in handling the special requirements of the elderly, more pharmacy educators are being trained in geriatrics, and pharmacy schools are offering more courses in geriatrics. The American Society of Hospital Pharmacists and the American Society of Consultant Pharmacists recognize and accredit residency programs in geriatric pharmacy, and the number of research-oriented fellowship programs in geriatric pharmacology is growing.