Meetings

European Society of Clinical Pharmacy

Pharmacy workforce and evidence-based practice were topics discussed at a recent international congress held in Paris. Harriet Adcock (on the staff of The Journal) reports

The 2nd International Congress on Clinical Pharmacy, jointly held by the European Society of Clinical Pharmacy and the American College of Clinical Pharmacy, took place in Paris from 28 to 30 April

Workforce issue is worldwide problem

Foreign-trained pharmacists

Movement within the global pharmacy workforce was the subject of an oral communication presented at the conference. Canadian researchers suggested that foreign-trained pharmacists could benefit from a tailored educational programme to improve communication skills and to help them apply their pharmacy knowledge in a different environment.

Lisa Dolovich, University of Toronto, Canada, said that the immigration of skilled health care professionals was helping to address the pharmacist supply/demand imbalance in Canada. She explained that over 25 per cent of registered pharmacists in Ontario were foreign-trained. For newly registered pharmacists the proportion was even greater, at 40 per cent. However, the influx of foreign-trained pharmacists had raised issues around quality assurance, with over 65 per cent of complaints against pharmacists directed towards those who were trained abroad.

To address the problem, the faculty of pharmacy at the University of Ontario had established a programme of training specifically for foreign-trained pharmacists. The programme includes competency-based prior-learning assessments, linguistic assessments and patient-care assessments.

Ms Dolovich said that, on the whole, there was not a gap in therapeutics knowledge for pharmacists trained outside Canada. Gaps tended to exist in terms of the application of knowledge and in communication. “Foreign pharmacists may meet general communication requirements. But for pharmacy-based skills, assessment that addresses things such as interpretation is needed,” she said. Another useful element to the programme, which has attracted over 400 applicants, was mentoring, which helped foreign pharmacists develop a professional network.

Concerns about skill mix and pharmacy workforce issues are not the sole preserve of the UK. They are also exercising the pharmacy profession in the US, where the population is set to increase to 325 million by 2020. Magaly Rodriguez de Bittner, of the Maryland school of pharmacy in Baltimore, calculated that, even with advances in technology that would release some pharmacists from dispensing activities, the profession in the US is likely to be short of 157,000 pharmacists by that time.

She warned that pharmacists would need to start looking closely at what they want for the profession and to make sure that they establish themselves as drug therapy experts. In line with arguments used in the UK, Ms Rodriguez de Bittner said that greater use of technicians would be needed and that technology would need to be embraced fully if pharmacists continued to move towards more expanded roles with a greater focus on patient-oriented services.

Addressing workforce issues faced in Europe, Alain Astier, Henri Mondor Hospital, Créteil, France, suggested that the seemingly unstoppable drive towards clinical pharmacy services would create problems. “Young pharmacists are pushed toward clinical pharmacy rather than technical pharmacy [for example, preparation of cytotoxic drugs and radiopharmaceuticals, control of drug supplies and preparation of drugs for clinical trials]. But we have to accept that these technical activities are related to clinical activities,” he said.

Commenting on the way pharmacy education is provided in the UK, Duncan McRobbie, St Thomas’ Hospital, London, said it was a failing of the system that pharmacists are trained as scientists rather than as clinicians at undergraduate level.

“A fundamental change that needs to occur in order to facilitate pharmaceutical care is to train people to be clinicians and then if they choose to become pharmaceutical scientists afterwards, we can move them in that direction,” he said.

However, there was some concern over the dilution of scientific training within undergraduate pharmacy courses. Gilles Aulagner, Louis Pradel Hospital, Bron, France, said: “In the future, we will be faced with new therapeutics such as gene therapy. Pharmacists can’t face the clinical problems posed by these very scientific therapies without an important background in science.”

The introduction of 10 new countries to the European Union (PJ, 1 May, p537) would also have an impact on the pharmacy workforce. Fernand Sauer, director of public health at the European Commission in Luxemborg, said there was clearly a health gap between the countries already within the EU and those entering it.

These new member states have few resources with high alcohol and tobacco consumption, and a high prevalence of certain diseases such as AIDS. There is also a fear that many health care professionals will migrate to wealthier parts of the EU. He added that the impact of movement of health care professions is unknown.

Patient interviews reveal most relevant problems

By using a variety of information sources — drug charts, case notes, laboratory data and patient interview — clinical pharmacists can avoid dwelling on drug-related problems that have little clinical relevance. This, in turn, would allow them to concentrate on more important care issues.

Researchers from Akademiska Hospital, Uppsala, Sweden, found that each of these four information sources was essential for identifying drug-related problems. In a study of 67 patients admitted to an acute internal medicine ward, 150 clinically relevant drug-related problems were recorded. Of these, 48 (32 per cent) were identified after studying the patient’s drug chart and through knowledge of the patient’s age and gender. After studying the patient’s case notes and laboratory data a further 26 new problems (17 per cent) were revealed and patient interview led to another 76 (51 per cent).

Presenting the results, Ulrika Engström said that an additional 82 drug-related problems had initially been identified when the patient’s drug chart was studied. It was only after collecting information from the other sources that the problems were found to be clinically irrelevant. “The patient interview reveals the most problems and these problems are likely to be the most important problems for the patient.”

A mean of 37 minutes was spent analysing all the information sources.

“Instead of covering all patients on all wards, clinical pharmacists should be more selective and conduct a more thorough screening,” Ms Engström concluded.

In a separate presentation, researchers from Northern Ireland showed that an intensive pharmaceutical care service reduced hospital readmission rates.

News p563

Pharmacists’ confidence is increased by CPD

Continuing professional development increases pharmacists’ confidence and is assumed to increase competence and improve services, Rose Marie Parr, of NHS Education for Scotland, contended. She added that the Royal Pharmaceutical Society’s CPD pilot study had shown that pharmacists given access to a CPD facilitator were much more likely to undertake CPD and make records than pharmacists who were not.

The pilot study involved a sample of 500 pharmacists from all areas of pharmacy practice within the UK. Half the cohort was allowed access to a CPD facilitator, who helped pharmacists understand what CPD was about and helped them identify and document their training needs. The remainder were left to cope with CPD on their own.

Ms Parr said that the pharmacy profession was heartened by the results of the pilot. “Pharmacists can and do carry out CPD.” However, she conceded that pharmacists tended not to document the CPD activities that they were engaged in. Indeed, they may not even recognise when they were engaged in CPD activities.

“The positive advantage with the facilitator was that pharmacists felt that once they had started to document their CPD, time was not such an issue as it was before they entered the pilot.”

Ms Parr went on to describe some of the challenges surrounding the introduction of mandatory CPD in the UK. One difficulty comes from the lack of evidence supporting educational theory. “We think we know that education and training is good, then we assume that CPD will make pharmacists competent. I don’t think this is an assumption we can make,” she said. Another challenge of introducing CPD will be to shift the mindset of pharmacists to think about the reflective cycle of learning.

On a more positive note, however, experience has shown Ms Parr that the profession has the self-confidence and motivation for continuing education. “We have to capture this for CPD,” she concluded.

Peter Vlasses, executive director of the Accreditation Council for Pharmacy Education, Chicago, described the US experience of mandatory continuing education. Research had shown that CE is effective in terms of providing knowledge but tends not to impact on the practice behaviour of pharmacists.

He suggested that the most successful CE programmes used interactive techniques. The limited changes in practice behaviours observed after 25 years of mandatory CE in the US were linked to the availability, or otherwise, of learning resources, the practice environment and motivation of pharmacists.

Strategies for motivation are needed and continuing professional development is now being studied as an enhancement aid to mandatory CE, he said.

Both Dr Vlasses and Ms Parr agreed that today’s pharmacy undergraduates were much better prepared for the challenge of CPD than their predecessors. Dr Vlasses said: “Many schools have moved towards a portfolio model in which students document what they have achieved. Undergraduates are now used to doing this.” Ms Parr echoed this view, adding: “The issues are with older pharmacists. Younger pharmacists can show us the way.”

Guidelines based on consensus lead to inconsistent patient care

Pharmacists’ perceptions

How pharmacists perceive evidence-based medicine was explored in a study conducted by researchers from the Midwestern University Chicago college of pharmacy in Downers Grove, Illinois. Jill Burkiewicz said that, on the whole, pharmacists welcomed evidence-based medicine and were willing to apply research findings to their practice.

The researchers questioned 318 pharmacists based in Illinois and found that most (89 per cent) had positive or somewhat positive attitudes toward evidence-based medicine and that 75 per cent supported the use of clinical practice guidelines to make patient-care decisions. Ms Burkiewicz pointed out that hospital pharmacists were more likely to have conducted a literature search in the past year than community pharmacists (75 per cent vs 30 per cent). And while 86 per cent of pharmacists reported having internet access at home, only 42 per cent said that they had access to the database PubMed at home. “Differences in the use of evidence-based medicine between practice settings generally arose from variations in barriers [such as lack of time, doctors’ attitudes and access to resources] rather than differences in attitudes,” Ms Burkiewicz concluded.

Clinical guidelines based on consensus rather than supported by an evidence base are likely to lead to inconsistency of care, said Marsha Raebel, pharmacotherapy research manager for a Kaiser Permanente managed care programme in Colorado. “Most thinking clinicians have strong opinions. Trying to implement guidelines based on consensus is largely unsuccessful.”

She was speaking during a session that explored how clinical practice guidelines could lead to improved patient care and what barriers existed to successful implementation. One problem is the introduction of guidelines that are not integrated into an existing care system. “Asking busy health care professionals to take on extra responsibility is a certain formula for failure of guideline implementation,” she added.

She went on to describe the successful use of two practice guidelines within Kaiser Permanente of Colorado. The first, a clinical pharmacy cardiac risk service, led to improved patient outcomes through evidence-based care. She explained that in 1998, 55 per cent of coronary artery disease patients within the Colorado Kaiser Permanente programme were having their cholesterol monitored but that only 22 per cent were being treated to reach a target of less that 100mg/dl for low-density lipoprotein cholesterol.

After the introduction of a service managed by clinical pharmacists, in which a guideline was used to standardise care, the percentage of patients being screened rose to 98 per cent, with 78 per cent being treated to the appropriate target.

An immunisation programme also made good use of practice guidelines. Kaiser Permanente introduced a tracking and reminder system and performance monitoring for clinics providing immunisation services. Copies of an immunisation guideline and a tool kit (giving information on vaccination schedules, storage of vaccines etc) were provided to all health care professionals, who also had direct telephone access to an immunisation specialist.

The tracking system allowed alerts to be made each time an unvaccinated child attended a clinic (for any reason). Ms Raebel said that, despite the state of Colorado receiving the least amount of funding for immunisation, rates for vaccination were higher within the Kaiser Permanente system than for the US as a whole (84 per cent compared with 81 per cent).

Successful implementation of guidelines with improvements in patient outcomes is largely based on the content of the guideline used, she explained. “A guideline based on strong evidence has a better chance of success.” There is also a need for knowledgeable staff and staff who are able to maintain adherence to guidelines. Feedback is also a factor so that clinic staff can see how they are doing and how they compare with previous years and with other regions, she added.