pharmacy practice and scope in ethiopia: an over view
TRANSCRIPT
Clinical pharmacy Education :
overview and scope of practice
Mohammed A. Mohammed
B.pharm, Msc.clinpharm
Clinical pharmacist and lecturer
11/11/2013 Mohammed A 1
Outline
• Overview of Clinical Pharmacy
• Global Perspective of Clinical Pharmacy Services
• Impact of clinical pharmacy services in the health care system
• Draw backs of the present pharmacy practice in Ethiopia
• Rationale for Shifting pharmacy practice to Clinical in Ethiopia
• Initiatives towards implementing Clinical Pharmacy Service in
Ethiopia
• Future directions
Mohammed A 211/11/2013
Overview of Clinical Pharmacy• “That area of pharmacy concerned with the science and practice of
rational medication use”
• Discipline in which pharmacists provide patient care that optimizes medication therapy and promotes health, wellness and disease prevention.
• It combine caring orientation with specialized therapeutic knowledge, experience, and judgment for the purpose of ensuring optimal patient outcomes.
• The practice embraces the philosophy of pharmaceutical care (PC)
ACCP
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Overview of Clinical Pharmacy…• PC is the new term introduced in recent years.
in contrast to what pharmacists have been doing for years.
“Pharmaceutical care is the responsible provision of drug therapy
for the purpose of achieving definite outcomes that improve or
maintain patient’s quality of life” (Hepler and Strand, 1990) & 1999 FIP
preventing a disease
elimination or reduction of a patients Sx
arresting or slowing of a disease process
cure of a disease
Practitioner assumes responsibility for a patient's drug-related needs and is heldaccountable for this commitment.
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Overview of Clinical Pharmacy…
• Accordingly, the policy sees pharmacists as a member of thehealthcare team. ‘’WHO and FIP 2000 Good Pharmacy Education Practice’’.
From a compounder of pharmaceutical products to a provider of services andinformation and
Ultimately that of a provider of patient care.
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Overview of Clinical Pharmacy…
• PC practitioners accept responsibility
• for optimizing all of a patient's drug therapy, regardless of the source(prescription, nonprescription, alternative, or traditional medicines),
• to achieve better patient outcomes and
• to improve the quality of each patient's life.
• The practitioner uses a rational decision-making process calledthe Pharmacotherapy Workup
• to make an assessment of the patient's drug-related needs, identify DRPs,develop a care plan, and conduct follow-up evaluations to ensure that all drugtherapies are effective and safe.
• Together, these steps are the patient care process.11/11/2013 Mohammed A 6
Overview of Clinical Pharmacy…
Clinical pharmacists primary work is
• to interact with the health care team,
• interview and assess patients,
• Make specific therapeutic recommendations,
• monitor patient responses to drug therapy and
• provide medicines information.
provide patient-oriented rather than
product-oriented services11/11/2013 Mohammed A 7
Overview of Clinical Pharmacy…
Clinical pharmacy requires
– An Expert knowledge of therapeutics
– A good understanding of disease process
– Knowledge of pharmaceutical products
– Drug monitoring skills
– Provision of drug information
– Strong Communication skills with solid knowledge ofthe medical terminology
– therapeutic planning skills and
– the ability to assess and interpret physical and
laboratory findings.
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Global Perspective of Clinical PharmacyDeveloped Countries
• In the last 4 decades the trend in the pharmacy practice moved
from medicine supplymore inclusive patient care
• Pharmacists role evolved from compounder, supplier of pharmaceuticals a provider of services, info & patient care.
• Practicing Pharmacists tasks are to ensure
pts drug therapy is appropriately indicated
the most effective meds are available for pts and
Safest possible and convenient for pts
Unique contribution for : DT outcome and pts Quality of life11/11/2013 Mohammed A 9
Global Perspective of Clinical PharmacyDeveloped Countries
• US and Iran: early 1960s: Pharm D
• US: 2000 Pharm.D mandatory for Pharmacy Schools
Other continents:
• Asia: India: Pharm.D: 2007
• Africa: Egypt: Alexandria University
• South Africa, Zambia: baccalaureate degree + internship in clinical areas
• UK, Australia, Malaysia, KSA, Jordan,Palastine:
M.clinpharm (MSc Clinical Pharmacy)11/11/2013 Mohammed A
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Global Perspective of Clinical PharmacyDeveloped Countries
• curriculum shift and economic transitions continue to reshape thepractice of pharmacy/scope.
(detection, resolution and prevention of DTPs).
Through implementation of clinical pharmacy services
85% EU hospitals some form CPS implemented.
• To date, clinical pharmacy services are implemented well at differentlevels of hospitals in many developed countries
• In some countries, this is no longer an exception but a rule
• The pharmacists are considered a knowledgeable drug expert and skilled,
persuasive communicator and not a pill counter.
These pharmacist embraced a new practice model – PC.
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Clinical Pharmacy services: perspective in Africa
• Pharmacy education (especially content) varies widely
• Most pharmacy schools widely use traditional curricula(limited resources), (SA, Ghnna, Keyna, Egypt)
• Scarcity of pharmacists may detract from training pharmacistsin clinical pharmacy provided by academic institutions.
• majority working in Business
• fewer learning opportunities in clinical pharmacy
• Although the relative need is greater.
• Unfavorable compensation packages and working conditions
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Clinical Pharmacy services: perspective in Africa
• ‘pharmacists in Africa have not fully adopted a new practice
philosophy.
• Practice still focuses on traditional dispensing and distribution
• Probably a combination of inadequate
Resources (easy to fix)
Knowledge (easy to fix)
Skills (easy to fix)
Attitude (hard to fix)
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Why clinical pharmacy services for
the health care system????
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Impact of clinical pharmacy services• During the last 25 years, pharmacists participating in team-based
care models in acute care or outpatient clinic settings have madepositive contributions to patient care quality and safe meds use
improved health and economic outcomes,
reduced meds related ADE, morbidity and mortality.
• Literatures show that the presence of clinical pharmacists in inpatient wards dec common DTPs, improve
patient outcomes and has Economic benefits
• impact of clinical pharmacy services in in-patient setting well documented. 1970s and 1980s
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Impact of clinical pharmacy services
• Direct pharmacist involvement and proper CPS implementation
in a variety of settings :
reduce Crisis in health care funding, cost of Rx,
saving hospitals money
drastically improve medication therapy outcomes.
‘’ A pharmacist who is unable or unwilling to adapt to a new
role places millions/billions of money at loss’’.
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CPS impact… Rx costs
Impact of CPS on Rx costs : USA
1. A US $100 million/ year health care system costs saved
adequately trained Pharmacists clinical intervention in community pharmacy
(Benrimoj et al. Economic impact of increased clinical intervention in community pharmacy. Pharmacoeconomics 2000 Nov;18(5):459–68.)
2. Provision of PC ambulatory care;
$45.6 billion (in 1995 U.S. dollars) in direct health care costs would be
avoided. Johnson et al. Drug-related morbidity and mortality: a cost-of-illness
model. Arch Intern Med 1995;155:1949–56.17Mohammed A11/11/2013
CPS impact… Rx costs
3. consultant pharmacists in nursing facilities
Bootman et al. The health care cost of drug related morbidity and
mortality in nursing facilities . Arch Intern Med 1997;157:2089–96
• cost of DRPs decreased from an
estimated $235 without consultant pharmacists
to $162 with consultant pharmacists
• total cost of managing drug-related morbidity and mortality was
$6.64 billion with consultant pharmacists and
$9.64 billion without consultant pharmacists.
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CPS impact… Rx costs
Australia
• reported that the annualized cost-savings associated witheconomically measured resources due to pharmacists’interventions was $4, 447 947 (AUS) in the 8 institutions;
• $23 were saved for every $1 spent on a pharmacist to initiate anintervention. Dooley et al. Br J Clin Pharmacol 2004;57:513-21.
Spain
• A hospital in Spain reported pharmacist interventions regardingantibiotic prophylaxis, PK, thromboembolism prophylaxis, and others wereassociated with a cost-savings of 129, 059 over a 6-month period.Galindo et al. Pharm World Sci 2003;25:56-64.
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CPS impact… Rx costs
Canada
• In Canada, the addition of a clinical pharmacist to an ICU resulted in pharmacist-initiated consultations leading to an annualized cost-savings of approximately $67, 665 (CAN) in 1994.
Malaysia
• The introduction of a part-time pharmacist into the ICU in Malaysia resulted in savings of $4,014 (US) over one month.
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CPS impact… Health outcome
• pharmacist-initiated drug therapy has Clinical impact
8 teaching hospitals in Australia. Dooley et al. Br J Clin Pharmacol 2004 ;57:513-21.
Of all the interventions made
• 25% were of major significance (preventing or addressing very serious
DRPs).
• 38% were of moderate significance (prevented major temporary injury,
enhanced the effectiveness of DT, or produced minor decs in patient morbidity
or a <20% chance of noticed effect), and
• 30.4% were of minor significance (small adjustments and optimizations
of therapy).
• 1% of the interventions documented were life-saving.
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CPS impact… Health outcome
Evidences from Hospital - Based studies in Africa
• In some African countries there have been major changes inthe provision of PC services in hospitals.
• Hospital pharmacists made a significant contributionto the reduction of meds errors andwork to scale up the safe, effective and economic use of meds.
• The most frequent clinical pharmacists’ interventions and contributions were related to
general information (42.9%),
the addition of new drugs (13.4%) and
dose adjustments (12.6%).
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What is wrong with the current pharmacy practice in Ethiopia?
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Drawbacks of the current/Old practicein Ethiopia
Pharmacists in practice know more about the productbut have little info about their patients.
Provide meds they know for patients they do not know
Not well trained in clinical sciences/ Pathophysiologycurriculum
Not well trained/lack skills
To collect and interpret patient specific data,
To take medication related histories
To identify drug- therapy related problems./DTPs
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Current/old Practice…
Other possible reasons
Lack of effective communication with patient ,caregivers and physicians.
Less frequent /no Pharmacists- physicians interaction
Pharmacists in practice fail to recognize themselves as member of the health care team. More to wards business
pharmacists’ recommendations Acceptance issues???
multifactorial:
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Current/old Practice…
Most drug therapy decisions are made by physicians
pharmacist’s role more reactive; (responding to prescribing
errors long after the decision has been made, and without having direct clinical knowledge of the patient).
Even If pharmacists able to detect any meds error,
Patient suffer more till the decision is made by the two parties.
Patients loss of trust on the professionals/services
negative impact on Rx outcomes
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Do we need to change Pharmacy
Education? (Ethiopia)
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Cont…
• In our country, Pharmacists are expert in most pharmacyspecialties………….is this enough?
Our patients, clinicians and the health care system lack PC
We need to apply the knowledge to patient care (direct patient care involvement)
all disciplines must become involved with and partly accountable for the whole process.
• The pharmacy services should Fill the existing gap in Patient Care; it is Not a Qs competition at all. neither its about propagandas.
Medical Care Nursing Care Pharmaceutical Care ???
• There is no future in the mere act of dispensing.
it is still essential in the new services philosophy
should be complemented by a wide variety of ward-based, community basedpatient-focused PC services and researches.
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Cont…
• Ethiopian Pharmacists should also• move from behind the counter and
• reshape the practice by providing care instead of pills only.
• We need a paradigm shift in the scope of pharmacy practice in Ethiopia: from product PC
‘’Pharmacists already in practice were mainly trained onthe basis of the old curriculum of product focus’’
• If these pharmacists are to contribute effectively to the new patient centered PC practice,
they must acquire the new knowledge and skills
required for their new role (PC). 11/11/2013 Mohammed A 29
Rationale for Shifting pharmacy practice
to Clinical in Ethiopia
• Pharmacy profession around the world has made a shift
in terms of education and scope of practice
» From lab-based to practical or clinical based.
» From technical aspect to professional aspect of pharmacy
• Are not we behind > 20 years from the rest of the world CPS?
30Mohammed A
11/11/2013
Rationale …why now???
• Major medicine-treatable diseases is increasing.
wide opportunities for PC .
• Prevalence of non-communicable diseases is increasing
DM, HTN, CVD, RF,Malignancyies, chronic illnesses.
Complexity of the mgt, DDI, ADE, monitoring,, New meds
demand to meds expert is clear
• Major issues with meds access, quality, and rational use
lack of communication b/n the ward teams and pharmacies
pharmacists must assume responsibility to prevent these meds reaching the clinicians and patients.
• Existing skills should be upgraded and linked to cope up with demand
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Rationale …
Evidences from our hospital
• A study done in JUSH Medical ward found that the prevalence of DRPs to be 73.5% among 257 study participants. Bereket et al ,2011
Of all the DTPS identified,
• 103(32.6%) of the DTPs were need additional drug therapy
• high dosage 49(15.5%).
• Unnecessary drug therapy 48(14.9%),
• low dosage 44(13.9%) and
• ineffective drug therapy 42(13.3%) .
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Rationale …
• Another study done in JUSH among outpatientsreceiving cardiovascular medications found that
the frequency of potential DDIs to be 241 (72.6%).
Legese et al,2011
Of all the potential DDIs identified,
– 200 (67.3%) were of "moderate" severity and
– 164 (55.2%) were delayed in on set.
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Rationale …
• A study done in JUSH ICU indicated that,
the Prevalence of medication prescribing errors 209 (52.5%) and administration errors were and 621 (51.8%).
Asrat et al,2011
• Of these identified prescribing errors
• wrong combination (25.7%),
• wrong frequency (15.5%) and
• wrong dose (15.1%).
• Medication errors associated with antibiotics took the lion's share in both medication prescribing (32.5%) and administration(36.7%) errors.
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Rationale …
A study done in JUSH among 339 women on ANC follow up showed that
236(69.6%) of the women used meds w/o prescribers order. And only
3 women prescribed FA
Mohammed et al, 2012
Of all these medications used during pregnancy
– 191(56.3%) cat-C followed by
– 165(48.7%) cat-B
– 57(16.8%) Category-D
– 24(7.1%) Category-X35Mohammed A11/11/2013
What has been done towards implementing Clinical Pharmacy Service in Ethiopia
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Initiatives in Ethiopia
• Curricular revision 2008: nationwide
• Pharmacy undergraduate curriculum: more patient oriented (4 years +1 internship)
• More than 40% of courses under new patient oriented curriculum areclinical pharmacy courses
• Advanced patient focused Postgraduate pharmacy training
MSC in Clinical Pharmacy JU Since 2009
MSC in Pharmacy practice AAU Since 2010
• In-service Clinical Pharmacy training for hospital
pharmacists. JU, 2012
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The Focus of the
New Pharmacy Curriculum
What do students mainly focus on ????
• Clinical Application of Drug Therapy
• Disease state knowledge
• Treatment guidelines and literature evaluations and
comparisons. For clinical use
• Diagnostic procedures (to identify a drug problem)
• Monitoring parameters (lab, PE, other diagnostic tools) to follow
safety of drug therapy.43Mohammed A11/11/2013
Goal of the new curriculum
The goal of Clinical oriented Training
• To make future Pharmacists experts in:
– identifying and solving DTPs
– becoming patient educators within their scope
– selecting the most effective therapy
– monitoring the outcome of drug therapy
– And highly involved in clinical practice and make better contribution to
patients Rx outcome
Provider of PC in a wider of settings
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• FMoH: EHRIG May 2010
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PC in Ethiopia
EHRIG …Clinical Pharmacy Services
Window of opportunity for pharmacists
• The hospital has policies and procedures for identifying
and managing drug use problems, including: monitoring
ADR, prescription monitoring and drug utilization
monitoring.(Operational standard 7)
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EHRIG …Clinical Pharmacy Services
Clearly state Clinical pharmacy Services as
• patient-oriented services developed to promote the rational use of medicines, and
more specifically, to maximize therapeutic benefits (optimize Rx outcomes),
• minimize risk, reduce cost, and support patient choice and decisions there by ensuring
the safe, effective and economic use of drug Rx in individual patients.
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EHRIG … Clinical Pharmacy Services
• clinical pharmacists should
– get information on medication histories,
– perform medication reviews,
– attend ward rounds,
– provide recommendations on drug selection andfollow-up,
– provide counseling to patients and health careproviders.
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EHRIG … Clinical Pharmacy Services
As member of the health care team, Clinical pharmacists will have the following functions:
Provide advice to– doctors, nurses and other health care workers on the clinical use of
Medicines, economic drug utilization and safety,
– hospital managers, including clinical managers to enable them to makeinformed decision with respect to medicines policy, procedures andguidelines
Offer direct patient care servicesthrough medication history-taking, medicines education and
advice, and
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Future directions of our Practice
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What is the fate of the “old model?
The old “Physicians Prescribe and Pharmacists Dispense” model
is no longer fully appropriate to ensure
reduce DTPs, safety, effectiveness and adherence to drug therapy.• prescriber was accountable for the results of pharmacotherapy.
(pharmacists were not responsible directly to patients for the cost, quality and results of PC)
• Health care costs: meds errors associated hospitalization, physicians visits, lab, mgt
• More than 50% of all prescriptions are incorrect
• >50% of the people fail to take their meds
• ADR:
4%–10% of all hospitalized patients. Developed countries
4th–6th leading cause of death in the USA
cost up to US$130 billion a year USA.
£466 million in the UK11/11/2013 Mohammed A 51
Future Direction
• To make future Pharmacists experts in providing PC:
In hospitals, clinics and community pharmacies
– identifying and solving DTPs
– becoming patient educators
– selecting the most effective therapy
– monitoring the outcome of drug therapy
And highly involved in clinical practice and
If pharmacy is to survive, we must cultivate pride andenthusiasm towards the profession in our students andfellow pharmacists .
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Future Direction• Professional commitment, teamwork, attitude change (possible)
– priority for patients/public services/profession
– Empower patients to take in-charge of their own health and treatment
– Effective utilization of available expertise of d/t specialties inta & inter profession
– Ethical standard practice,
Senior staffs ……..
• Pharmacy schools
» Resource sufficiency– Budget
– adequate preceptors for clinical attachment
– Facilities /experiential sites
– must produce graduates capable of responding to the challenges of society's needs and professional evolution, and
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Future Direction
• Strengthening/establishing Healthy professional r/pwith other fellow pharmacists and other health care teams
• learn from others wealth of professional experience on the new philosophy (intra and from other professions)
• Hospitals need to develop policies for clinical pharmacy services. Integration of Pharmacy med review charts etc.
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Future Direction…
• Policymakers’ awareness (Pharmacists as part of healthcare team,
regulations, and standard of pharmacy)
• FMoH (pharmacy wing), FMHACA, EPA
should be a dedicated to lift up and reshape the
future pharmacy education and scope of practice.
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‘The future of PHARMACY profession does notonly depend on those who are willing topractice pharmacy to the highest standards; italso relies heavily on those who are willing togive of their time and energy to work for theprofession in general’.
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THANK YOU FOR YOUR
KIND ATTENTION!
11/11/2013 Mohammed A 57