Overview of patientcentered clinical outcomes achieved through pharmacist managed clinics within a c

1
Overview of patient-centered clinical outcomes
achieved through pharmacist managed clinics
within a comprehensive Indian Health Service
facility further evidence for the need of
pharmacist provider reimbursement

• LT Carl Murray, PharmD.
• Pharmacy Resident
• Claremore Indian Hospital

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Objectives

• Describe the need for outcomes tracking within
  pharmacist-managed clinics
• Claremore Indian Hospital ACC, Dyslipidemia, and
  CHF outcomes data
• List established guidelines/literature for
  outcomes comparisons

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Outcomes

• Patient centered care is now the widely excepted
  healthcare goal
• Medicare is paving the way for billable
  medication therapy management services
• Pharmacists are being recognized for their
  ability to produce positive patient outcomes

Am J Health-Syst Pharm. 200764590-2
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Outcomes

• Greater effort should exist in the publication of
  these results to help justify reimbursement for
  pharmacists cognitive abilities
• Clinic outcomes must continually be monitored and
  benchmarked to assure therapeutic goals are met
  and patients receive optimal healthcare

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Clinics

• Anticoagulation
• Dyslipidemia
• Congestive Heart Failure

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Anticoagulation Clinic

• Clinic background
• 8/20/01 to 9/30/07
• Total of patients- 741
• Patient years- 1025
• Guidelines- ACCP Chest 2004
• Outcomes
• TTR (time in therapeutic range), ER visits,
  hospital admits

Chest 2004 Sep 126 (Suppl) 163S-696S
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ACC Outcomes Database
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ACC Outcomes Database
9
ACC Outcomes Database
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ACC Outcomes Database
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ACC Outcomes Database
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Anticoagulation Clinic

• Established Comparisons
• The Chiquette et al. trial compared a pharmacist
  managed ACC with usual medical care.
• Walraven meta-analysis contained 67 studies
  evaluating anticoagulation clinics

Arch Inter Med 19981581641-7
Chest 20061291155-66
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Anticoagulation Clinic

• IHS and Chiquette TTR was calculated using the
  linear interpolation. The Walraven
  meta-analysis found 79.7 used linear
  interpolation to calculate TTR.
• Inclusion criteria for ER visits primary purpose
  of visit was warfarin-related.
• Inclusion criteria for hospitalizations primary
  admission diagnosis was warfarin-related.

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Anticoagulation Clinic

• TTR is presented as percentage ()
• ER visits are presented as number of visits per
  100 patient years
• Hospitalizations presented as number of admits
  per 100 patient years

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Dyslipidemia Clinic

• Clinic background
• 4/1/98 to 5/16/03
• Total of patients- 224
• Guidelines- NCEP ATP III
• Outcomes
• Mean LDL reduction, LDL goal achieved, mean TG
  reduction, TG goal achieved

NCEP/ATP III. 2001
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Dyslipidemia Clinic

• Established Comparisons
• The ACTION Trial compared a pharmacist-managed
  dyslipidemia clinic with usual medical care.
• The ImPACT trial demonstrated a collaborative
  care model utilizing pharmacists and physicians

Pharmacotherapy. 200525360-71
J Am Pharm Assoc. 2000 40157-65
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Dyslipidemia Clinic

• LDL and TG reductions are shown in percent
  milligram per deciliter (mg/dL) change from
  baseline
• LDL and TG goals achieved are shown in patient
  percentage
• For ImPACT only- Mean LDL and TG reduction data
  contained patients with LDL goals of lt160, lt130,
  and lt100.

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CHF Clinic

• Clinic background
• 8/1/04 to 11/1/07
• Total of patients- 39
• Guidelines- 2005 ACC/AHA
• Outcomes
• Pts on ACE/ARB or CI, pts on BB or CI,
  readmission rates at 9 and 15 months

Circulation 2005112e154-e235
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CHF Clinic

• Established Comparisons
• ADHERE - Acute Decompensated Heart Failure
  National Registry, the Final Cumulative National
  Benchmark Report
• The Pawanant et al. article is an analysis of
  Medicare data looking at trends in heart failure
  rehospitalization rates 28,919 patients
  identified

http//www.adhereregistry.com
J Card Fail. 200713S149-50
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CHF Clinic

• Inclusion criteria for CHF clinic diagnosis of
  systolic heart failure (defined as ejection
  fraction lt 50 percent)

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CHF Clinic
ADHERE / Claremore CHF Clinic Percent of
patients discharged from hospital with CHF
diagnosis on ACE/ARB or CI BB or CI Pawanant /
Claremore CHF Clinic Percent of hospital
readmissions after initial admission at 9 months
and 15 months
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Conclusion

• Our results demonstrate that pharmacist-managed
  clinics at Claremore IHS Hospital are comparable
  with established pharmacist-managed clinics and
  non-inferior to usual medical care found in
  literature.
• Achieving these clinical outcomes provides
  further support for pharmacist provider
  reimbursement.

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Reference

• Altman JS. Medication therapy management and the
  new practitioner. Am J Health-Syst Pharm.
  200764590-2.
• The Seventh ACCP Conference on Antithrombotic and
  Thrombolytic Therapy Evidence-Based Guidelines.
  Chest 2004 Sep 126 (Suppl) 163S-696S.
• Chiquette E, Amato MG, Bussey HI. Comparison of
  an anticoagulation clinic with usual medical
  care anticoagulation control, patient outcomes,
  and health care costs. Arch Inter Med.
  19981581641-7.
• Van Walraven C, Jennings A, Oake N, et al. Effect
  of study setting on anticoagulation control a
  systematic review and metaregression. Chest.
  20061291155-66.

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Reference

• Expert Panel on Detection, Evaluation, and
  Treatment of High Blood Cholesterol in Adults.
  Third report of the national cholesterol
  education program (NCEP) expert panel on
  detection, evaluation, and treatment of high
  blood cholesterol in adults (adult treatment
  panel III). Bethesda, MD National Heart, Lung,
  and Blood Institute, Public Health Service,
  Department of Health and Human Services, 2001.
• Straka RJ, Taheri R, Cooper SL, et al. Achieving
  Cholesterol Target in a Managed Care Organization
  (ACTION) Trial. Pharmacotherapy. 200525360-71.
• Bluml BM, McKenney JM, Cziraky MJ. Pharmaceutical
  care services and results in project ImPACT
  hyperlipidemia. J Am Pharm Assoc. 2000 40157-65.

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Reference

• Hunt SA, Abraham WT, Chin MH, et al. ACC/AHA 2005
  guideline update for the diagnosis and management
  of chronic heart failure in the adult.
  Circulation 2005112e154-e235.
• Acute Decompensated Heart Failure National
  Registry (ADHERE) Q1 Final cumulative national
  benchmark report. http//www.adhereregistry.com
• Puwanant S, Johnson JW, Conti JB, et al. Current
  trends in heart failure rehospitalization rates
  analysis of Medicare data. Heart Failure Society
  of American Annual Meeting Abstracts. J Card
  Fail. 200713S149-50.

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Questions