Hospital Pharmacist
Vol 11 No 1 p25-29
January 2004

American Society of Health-System Pharmacists

The American Society of Health-System Pharmacists’ midyear clinical meeting was held in New Orleans, USA, from 7 to 11 December 2003. Gareth Jones, Christine Clark and Laurence Goldberg report

Medicare [the publicly funded US health service for people aged over 65] will be impossible to fund by 2015, suggested James Orlikoff, a health care consultant, delivering the keynote address to the conference of the American Society of Health-System Pharmacists. There are currently three taxpayers for every person receiving retirement benefits, but this ratio is likely to reduce over the next 10 years. The cost of health care is continuing to rise at the same time as the baby-boomer population is retiring, leaving fewer workers to pay taxes. There are other downward pressures on government income derived from taxation. America’s health system will face some of the same challenges as the NHS with a need to ensure value for money from health treatment. Mr Orlikoff said that it would be impossible for health economies to offer universal health benefits to everyone over the age of 65, which is an arbitrary figure selected many years ago in a time of shorter life spans. The health care system will be forced to change to adapt to new realities, he predicted.

The principle of health and social benefits for people over the age of 65 dates back to Bismarckian Germany, said Mr Orlikoff. In order to provide the illusion of the state caring for the elderly in retirement, Chancellor Bismarck investigated the costs of introducing state benefits for people over the age of 65. In 1870, 95 per cent of the population were dead at this age, and 95 per cent of those alive would die within two years. This meant that the old age benefits offered were inexpensive to the population as a whole. However, life-spans have increased, and the current actuarial equivalent of 65 in 1870 is 92. Mr Orlikoff predicted a revolution as the dwindling numbers of taxpayers refuse to carry the burden of supporting the increasing number of pensioners.

Why have health care costs been going up at above the rate of inflation asked, Mr Orlikoff: it is because of the insatiable expectation of the population about what health care can achieve for them. Health care perverts the rules of economics and supply creates its own demand. With health care, most of the population want to receive every available treatment, as soon as possible, and they want it to be funded by someone else. As health care gets more expensive, employers that offer it as a benefit will increasingly withdraw it, forcing more people to obtain health care from the public system, thus increasing the pressures on the public purse.

There is a paradox in the US health care system in that increasing numbers of people are unable to afford basic medical insurance, at the same time as more innovative therapies (eg, new pharmaceuticals, genomics, proteomics, robotic surgery) are becoming available to a small number of people who can afford them. He predicted that more expensive new technologies would be approved for use, but would not be available on Medicare or other health insurance schemes. This would lead to the concept of affluent medicine, with about 20 per cent of the population being able to afford the latest expensive therapies. There would be an increase in retail medicine where people would simply purchase the care as they need it. As more money is spent on health care, quality will become more important, whether paid for by the government or the individual. He predicted that the solutions for the US health system were means testing, aggressive rationing, increased taxes and raising the age at which people become eligible for Medicare.

More money is spent on health care in the US than is generated by the entire economy of the UK. With over 15 per cent of the gross domestic product being spent on health, Mr Orlikoff asked participants to consider the purpose of health care. He suggested that society should stop thinking that keeping people healthy supports the economy. The majority of health care services are provided to people who are of retirement age, and are no longer contributing to the economy. In fact, the more money that is spent on health care, the less competitive an economy can be.

The new Medicare bill was enacted in the US on 8 December (Pharmaceutical Journal 2003:271;834). Dr Joseph Antos of the American Enterprise Institute described the changes as the biggest since Medicare was introduced in 1965. The changes were caused by the increase in the elderly population and the increase in the availability and cost of health care interventions.

Until now, Medicare has not covered the cost of outpatient prescription drugs, and over 90 per cent of those eligible for Medicare have sought additional cover from mainly private medical insurance schemes. Medicare has also provided a limited contribution towards the cost of hospital stays and prevention services. There has been no limit on what an individual patient may pay.

The new legislation will allow for a prescription drug scheme from 2006. Patients would still pay the first few thousand dollars a year for their drug treatment, but after this they would only pay a small proportion of the actual cost. Until the scheme is implemented, a card will be available, funded by the government, offering discounts of between 10 and 25 per cent on drug prices. There is no provision for price controls of prescription drugs, but this may come later. The lack of measures to force pharmaceutical companies to lower their prices has met with stiff opposition from the democratic party. Increasing importation of cheap pharmaceuticals from Canada has stimulated an awareness among Americans that they pay more for their drugs than most other populations in the world.

High-alert drugs continue to harm patients

High-alert medications continued to harm patients in 2002 according to Diane Cousins, vice president of the Centre for the Advancement of Patient Safety (CAPS), quoting the United States Pharmacopeia (USP) MEDMARX report. As in 2001, eight of the 10 products most often involved in medication errors were high-alert medications (insulin, morphine, heparin, potassium chloride, warfarin, fentanyl, hydromorphone and meperidine [pethidine]) and these eight accounted for 35 per cent of all the errors that resulted in patient harm.

In 2002 MEDMARX received 192,477 medication error reports from 482 health care institutions, representing increases of 82.2 per cent and 31 per cent respectively. Errors are categorised broadly as potential errors, non-harm errors and harm errors. In 2001, 98 per cent of errors did not cause harm and 15 per cent of events had the potential for error. Astute practitioners were able to avert errors on 35 per cent of occasions. Almost half (49 per cent) of errors reported actually reached the patient and 1.67 per cent were harmful. The number of deaths associated with medication errors rose from three in 2001 to 14 in 2002.

Errors are categorised by the stage of the medication use process at which they occur (ie, prescribing, documentation [transcribing], dispensing, administering, monitoring). Thirty-three per cent of errors were reported at the administration stage, one per cent during monitoring and the remainder were more or less evenly distributed over the other three categories. There had been a 40 per cent increase in reports of errors at the prescribing stage compared with 2001, and this was more likely to be due to improved reporting rather than deteriorating prescribing, said Ms Cousins.

The 2002 report focused on four of the national patient safety goals set out by the Joint Commission on Accreditation of Healthcare Organisations (JCAHO). JCAHO, the body responsible for accrediting US hospitals and health care institutions has identified seven patient safety goals that take effect from 1 January 2004; they are:

• Improve the accuracy of patient identification
• Improve the effectiveness of communication among caregivers
• Improve the safety of high-alert medications
• Eliminate wrong-site, wrong-patient and wrong-procedure surgery
• Improve the safety of using infusion pumps
• Improve the effectiveness of clinical alarm systems
• Reduce the risk of health care acquired infections

Misidentified or “wrong-patient” types of error occurred in 4.7 per cent of reports and involved all phases of the medication use process. One error of this type was caused when a nurse took a telephoned report of a blood sugar measurement and wrote down the wrong room number. Sliding scale insulin was prescribed and given to the patient with the corresponding room number, said Ms Cousins. Communications issues were found to be the third leading cause of errors. Dr Paul Schyve, senior vice president, JCAHO, pointed out that the commission now recommended that hospitals should implement formal procedures for taking telephone orders and receiving results. “Staff must write them down and read them back — merely repeating them is not enough,” he said.

About nine per cent of the reports involving errors with infusion pumps were harmful to patients. There were two fatal incidents involving infusion pumps and both were due to errors in programming the pumps. Again, high-alert medications remain a problem, and despite the fact that the list is well-known and commonly reported, institutions appear to find it difficult to devise safe methods for their use.

Summing up, Dr Schyve said that the USP data clearly demonstrate the need to improve patient safety through renewed efforts to prevent patient misidentification, miscommunication between caregivers, errors in administration of high-risk medications and infusion pump errors.

LMWH — cost and quality improvements

Low molecular weight heparins (LMWHs) accounted for more than five per cent of total drug expenditure and incorrect dosing was a common problem, according to an audit conducted by Dr Regina Brophy at the Royal United Hospital, Bath, and presented as a poster.

Many patients were not weighed (to calculate the correct dose they should be given) before treatment was started and more than 30 per cent of medical patients who were weighed were still prescribed an incorrect dose.

After consultation with all clinical leads, the local drug policy group decided that enoxaparin should be used as the LMWH of choice. This immediately reduced spending on LMWHs by 25 per cent.

US consumers call for drug error reporting

Errors remain a significant cause of preventable death in the USA according to Arthur Levin, director of the Centre for Medical Consumers. Speaking at the annual Cheers Awards held by the Institute for Safe Medication Practices (ISMP), Mr Levin said that given the current state of knowledge it would be irresponsible to accept anything less than a 50 per cent reduction in medication errors. It is not acceptable for patients to be harmed by the health care system and at present the pace of change (towards reduction of medication errors) does not reflect the sense of urgency in the Institute of Medicine (IoM) reports. Errors are more often tackled through more research rather than by measures to prevent their occurrence.

Studies show that doctors and consumers routinely underestimate the number of deaths due to medication errors. “Instead of a public outcry, there is barely a whimper,” said Mr Levin. A sum of $60m (£35m) has been set aside for safety initiatives but it is not sufficient. Mr Levin called on consumers to be more critical of the Government in this regard. One billion dollars would only be a tiny fraction of government spending and could usefully be spent on safety. The IoM has asked the Federal Government to take a lead in this area but it is content to move slowly.

At present there is no way to know how well current efforts are progressing. Accountability and transparency are critical issues. Secrecy is lethal to democratic principles. Much of today’s effort is anything but transparent. For example, in a recent survey, 86 per cent of doctors compared with 34 per cent of the public felt that error reports should be confidential. Doctors think that patients do not need to be told about all errors but the public thinks that they should. In return for their licences to practise, professionals agree to regulate themselves but the IoM reports show that this arrangement has not worked. “The promised good intentions of professionals are not enough — trust has been lost,” he said.

A nationwide mandatory system of reporting adverse events is needed. A suggestion from the IoM that some adverse events should be publicly disclosed aroused intense opposition and subsequently disappeared from the agenda, noted Mr Levin. The IoM envisaged that all states would participate and that each one would be required to provide annual standardised aggregated information. Voluntary systems have problems because of selective opt in or opt out arrangements, he added. Furthermore, in public eyes, voluntary and confidential systems are the opposite of transparent and accountable systems.

ISMP has called for indication statements to be written on prescriptions, a move that Mr Levin supports. If the pharmacist is to participate in the team then he must have access to full information, he said. “Most patients will choose safety over fears about privacy,” he added. Written consumer information about medicines could also be improved. Three decades of voluntary effort should have been enough to get it right and it is now time for a mandatory guide to apply, he said. It is time to put some teeth behind the legislation in those states that require counselling by a pharmacist if patients request it. Counselling by doctors is known to be inadequate.

Mr Levin was irritated by a suggestion that patients had a responsibility to prevent medication errors, saying that the responsibility rests with those who run the health care system. Patients should educate themselves and understand the risks and benefits of their treatment, he said, but the health care system cannot “lay off” responsibility because a patient may be too sick to help himself.

SARS — further outbreaks not inevitable

Carriers of the coronavirus which causes severe acute respiratory syndrome (SARS) may not be present in the human population, according to Thomas File, professor of medicine, Northeastern Ohio Universities, College of Medicine. While this means that a repeat of the outbreak earlier this year is less likely, it is still possible that animal carriers (such as exotic animals in China) could spread the disease. Serological evaluation of 1,500 asymptomatic health care workers in Toronto, who were responsible for much of the spread of the virus, has shown that 10 are seropositive for the novel coronavirus which causes the disease. A further study of 574 GPs in Hong Kong, where a number of doctors died from SARS, found that none were seropositive. This suggests that once a person becomes infected, they are highly likely to develop SARS. For most viruses, there are large groups of people who are infected but are asymptomatic, but this appears not to be the case with SARS. As a result, it is less likely that there is a reservoir of SARS in the human population that could re-emerge.

There is strong evidence linking this novel coronavirus with SARS from different laboratories across the world, said Professor File. Various coronaviruses have previously caused infections in the human population. The coronavirus that caused SARS is genetically distinct from all these known coronaviruses. Previously identified coronaviruses have mainly caused mild upper respiratory tract infections such as the common cold. This new coronavirus, causing serious morbidity and mortality, is unique.

At the early stages, SARS could be confused for influenza. This increases the importance of immunising the at-risk population against flu, to prevent the concern and confusion that may occur if there are concurrent outbreaks of SARS and flu. Professor File highlighted this as an area where pharmacists could help, by encouraging their at-risk patients to be vaccinated against flu.

The first SARS death is believed to have occurred in the Guangdong province of China on 16 November 2002. A doctor who had been treating SARS patients travelled to Hong Kong in late February 2003 and stayed at the Hotel M. Twelve people staying in that hotel later developed SARS, taking the disease to Canada, Ireland, US, Singapore and Vietnam. The guest who developed SARS in Vietnam was treated by Dr Urbani from the World Health Organization. He defined the epidemiology and coined the term SARS, but subsequently died in Bangkok from the disease. It has now affected 8,500 people, mainly healthy adults between the ages of 25-70, and 9.5 per cent have died. The last reported natural case was in late June 2003, with a further laboratory-based case reported in August [a case has subsequently been reported in China].

The clinical characteristics of SARS are an incubation period which is normally between two and seven days, although cases of 11 days have been reported. Initially, there is a prodrome, often with fever, chills, malaise and myalgia, but there is no evidence of cough. This is followed by a lower respiratory tract infection with a cough, with 10-20 per cent of patients requiring mechanical ventilation. Laboratory characteristics include leucopenia, thrombocytopenia, lymphocytopenia, elevated lactate dehydrogenase (LDH), elevated creatine kinase and abnormal liver function tests.

Professor File said that between 25 and 70 per cent of all SARS patients are health care providers. Transmission was stopped by effective isolation of patients with the virus. No antiviral treatment has been shown to be clinically effective for SARS. Some patients have been given ribavirin, although the risks are thought to outweigh the benefits. One of the benefits of the SARS outbreak is the improvement in the world’s public health system. We are now much better prepared for a major pandemic such as flu, said Professor File.

IV drug safety

Risk assessment tools to assign overall risk scores (ORSs) to a range of parenteral injections were developed by Alison Beaney, Anne Black and Clare Dobson (Newcastle upon Tyne Hospital NHS Trust). The authors presented a poster on their work which had been awarded the joint Baxter Healthcare and Guild of Healthcare Pharmacists award 2002.

The scoring system takes account of up to 11 factors, including the background environment and whether or not the operator is familiar with the reconstitution/dilution process. The ORSs were calculated for 2,722 products in different situations. The maximum possible score is about 70 but products with a score of above 15 are considered to require additional care. Approximately 10 per cent of scores fell into this category. As a result of the project, the highest risk items are now prepared in the pharmacy and the options for ready-to-use syringes are being explored. There is also additional pharmacy input into nurse training and a standardised protocol for the preparation of parenteral doses is displayed on wards.

Low health literacy causes suffering

Low health literacy causes needless suffering, hinders patients from taking an active role in managing their own health care and increases disparity in health care access according to Terry Davis, professor of medicine and paediatrics, Louisiana State University Health Science Centre. Health literacy is an individual’s capacity to obtain, process and understand basic health information and services, make appropriate decisions and navigate the health care system. Low literacy is particularly a problem in US cities, with between 35 and 45 per cent of children dropping-out of school before completing their education. Twenty-one per cent of adults have low literacy. The institute of medicine has listed improving health literacy as a top priority.

There is a 52 per cent increased risk of hospitalisation in patients with low health literacy. This, along with ineffective drug taking and misunderstood treatment plans is responsible for much wasted resources. It has been estimated that $50bn (£29bn) is wasted annually as a result of low health literacy. Signs of patients with low health literacy include those with poor compliance, no knowledge of the name or purpose of medicines or patients who ask few questions. These patients can also appear angry, slippery, clowning or passive, which is a sign of their inability to understand what is happening.

Written material given to patients should avoid information overload, and be simple and to the point, said Professor Davis. Fourteen per cent of patients remembered the counselling when advice was spoken, but when a pictogram was also shown 85 per cent remembered. Only 37 per cent of parents were correctly able to use an oral syringe to administer to their children following a verbal description. One hundred per cent were able to do this when the syringe was marked with the dose, the patient was given a demonstration, and their understanding was checked.

Professor Davis summarised the key points for ensuring good communication with patients: Limit information (three key points), give the most important information first, be specific, confirm understanding, repeat the information and be positive. Explanation, assessment and clarification are all required when delivering information to a patient to ensure understanding.

Vaccination and other innovations for pharmacy

Innovative pharmacy practice was recognised at the American Society of Health-System Pharmacists 2003 best practice awards, with the six winning teams presenting their projects.

Immunisation rates in at-risk patients can be improved when pharmacists investigate immunisation status according to Dr Jill Robke and colleagues from St Luke’s Hospital, Kansas City, Missouri. In June 2001, questions were added to the admission questionnaire at the hospital, to find out if patients had been immunised with the pneumococcal and influenza vaccines. If no immunisation was recorded, the patient was flagged up for the pharmacist who would then review the patient’s notes to check for indications and contra-indications for the vaccines. If vaccination appeared to be indicated, the pharmacist educated the patient, and sought consent for immunisation from the patient and their doctor.

The rate-limiting step in this process was the time spent trying to contact the doctor. A policy was therefore accepted which enabled medical staff to give a blanket agreement for any of their patients to be vaccinated on the request of a pharmacist.

Dr Robke and colleagues reported that the amount of pneumococcal vaccine dispensed in the hospital has quadrupled. This is a significant intervention because immunisation of high-risk patients against pneumococcus and flu has been shown to reduce hospital admission by 72 per cent and 82 per cent respectively. The hospital is now meeting its target of immunising 90 per cent of elderly people.

Emergency department

Seventy-three major medication errors have been averted by a pharmacist working in the emergency [accident and emergency] department of a hospital according to Diane Barker and colleagues from the Medical Centre of Aurora, Colorado. Nineteen would have been life threatening had they occurred. Savings of $147,000 (£86,000) have been recorded.

A pharmacist works in the department 10 hours per day for six days of the week, covering the peak period of 2pm to midnight. This pharmacist attends and assists with cardiopulmonary arrest and trauma situations, reviews prescriptions, obtains and documents medication and allergy histories, provides discharge patient education, completes and monitors drug information requests and documents adverse reactions. The pharmacist also performs staff education services, drug cost analyses, trains current and future practitioners, and participates in ongoing quality improvement and research.

Dr Barker and colleagues stressed the importance of the role of the emergency room pharmacist by saying that, “pharmacy has an opportunity to touch more patients in the emergency department than any other unit in the hospital.”

Pharmaceutical care

Patients benefit from pharmaceutical care clinics where pharmacists deal with their drug-related problems. Leigh Ramsey and colleagues of the University of Mississippi Medical Centre, Jackson, Mississippi, developed pharmacist-led clinics in asthma, diabetes, oral anticoagulation and lipid management.

Pharmaceutical care clinics are staffed by six full-time pharmacists, and they receive support from a medicines information centre. Doctors select target patients and refer them to the pharmaceutical care clinic, where they can see a pharmacist up to 12 times a year. There was a 47 per cent reduction in hospital admissions for bronchospastic decompensation among asthma patients attending the clinic. The average HbA1c for patients attending the diabetes clinic reduced from 9.9 to 7.7 per cent. Forty per cent of patients reached the American Diabetes Association’s goal for glycaemic control of HbA1c <= 7.0 per cent.

There were also significant cost savings, averaging $2,655 (£1,500) for each patient, achieved by a reduction in the number of times that patients were admitted to hospital.

Community mental health

Clinical pharmacy services can be offered to clients at a community mental health centre. Thomas O’Brien and colleagues set-up a service to help clients as they recover and reintegrate into the community.

The “Strong Ties” centre provides out-patient psychiatric services to 1,100 clients with severe and persistent mental illness. Before 2000, patients did not receive a consistent pharmacy service, there was no medicines management and patients had no contact with pharmacists specialising in psychopharmacology. The aim of the new pharmacy service was to enhance adherence to treatment by providing pharmaceutical care services, develop client focused initiatives and serve as a psychopharmacology resource.

The pharmacy has started clinics providing pharmaceutical care for patients with diabetes. Other activities include support for a smoking cessation programme, a treatment adherence programme and clinical research.

Pharmacist lipid clinic

Significant reductions in low density lipoprotein (LDL) levels can be achieved by a pharmacist-run lipid clinic. Pharmacists at the Patrick Air Force Base in Florida established standards of care with local doctors. Five hundred and twenty-seven patients were identified from a database of mainly retired members of the military as having dyslipidaemia and not being at the target LDL.

Fifty-seven per cent were non-adherent or not prescribed therapy specified in the standards and 32 per cent were receiving a sub-therapeutic dose. Unsafe combination therapy was found in 14 per cent of patients and 32 per cent were receiving the wrong choice of drug.

Community doctors referred patients to the pharmacy-led clinics and LDL levels reduced by 26 per cent. In a group of patients who had not previously reached their LDL target, 69 per cent reached this target after pharmacist intervention. Projected savings from reducing hospital admissions was $9.5m (£5.5m).

Barcodes prevent errors

Point of care barcode medication scanning can reduce the incidence of adverse events due to incorrect medication administration, according to Steve Rough and colleagues of the University of Wisconsin Hospital and Clinics.

Barcode scanning technology was installed in the hospital. A mobile unit scans the nurse’s personal identification barcode, a barcode attached to the medication box and a barcode on the patient’s identity wrist strap. The nurse is alerted by the system if the patient and medication bar code do not match. Medication administration accuracy has increased from 92 per cent to 100 per cent.