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Encyclopedia of
CIin ical Pharmacy

Encyclopedia of
Clinical Pharmacy

edited by

Joseph T. DiPiro
Panoz Professor (fPharmacy
University of Georgia College of Pharmacy
Athens, Georgia, U.S.A.
and
Clinical Professor of Surgery
Medical College of Georgia
Augusta, Georgia, U.S.A.

College of
Clinical Pharmacy

*
0

Taylor & Francis

Taylor & FrancisGroup
Newyak Landon

ISBN
Print: 0-82474752-4
Online:0-8247-0608-0
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Marccl Dckkcr
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Copyright 0 2003 by Marcel Dckkcr

(except as noted on the opening page of each article.) All Rights Reserved.

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PRINTED IN THE UNITED STATES OF AMERICA

Encyclopedia of
CI inical Pharmacy

Editorial Advisory Board

Paul Abramowitz, Pharm.D.

University of Iowa, Iowa City,

Iowa, U.S.A.

Chris Alderman, B Pharm. FSHP, BCPP, CGP

University of South Australia,

Daw Park, Adelaide, SOUTH
A USTRALIA

Steven Barriere, Pharm.D.

San Francisco, Califnrnia, U.S.A.

Joaquin Bonal de Falgas

Pharmaceutical Care Spain

Foundation, Barcelona, SPAIN

Gerhard Carstens

St. Bernward Apotheke, HannoverDoe h ren, GERMANY

George Dukes, Pharm.D.

GlaxoSmithKline, Research
Triangle Park, North Carolina,
U.S.A.

Robert M. Elenbaas, Pharm.D., FCCP

American College of Clinical

Pharmacy (ACCP), Kansas City,
Missouri, U.S.A.

Laurence Goldberg, FRPharmS

Buy, hcashire, UNITEL)KNGDOM

William A. Gouveia

Tufts-New England Medical Center;

Boston, Massachusetts, U.S.A.

Thomas Hardin, Pharm.D., FCCP

Ortho-McNeil Pharmaceutical, Inc.,

San Antonio, Texas, U.S.A.

Mary Anne Koda-Kimble, Pharm.D.

University of California at
San Francisco, San Francisco,
California, U.S.A.

Milap C. Nahata, Pharm.D.

The Ohio State University,

Columbus, Ohio, U.S.A.

Atsuhiko Nishitani, Ph.D.

Juntendo University Hospital,

Tokyo, JAPAN

Cynthia Raehl, Pharm.D.

Texas Tech University HSC at

Amarillo, Amarillo, Texas, U.S.A.

Myrella Roy, Pharm.D., FCCP

Consultant, Ottawa, Ontario,

CANADA

Barbara Wells, Pharm.D., FCCP, FASHP, BCPP

University of Mississippi, University,

Mississippi, U.S.A.

Georges Zelger, Ph.D., PD

Pharmacie des hdpitaux, du Nord

Vuudois et de la Broye, Yverdon-lesBains, SWIKZERLAND

List of Contributors

Marwan S. Abouljoud i Henry Ford Hospital, Detroit, Michigan, U.S.A.

Azuccna Aldaz 1 Clinica Universituria de Navarru, Iamplona. Spuin
Christopher P. Alderman i Repatriation General Hospital, Adelaide. Australia
Kathryn T. Andrusko-Furphy / Atuscadero. Culifirnia, U.S.A.
Joint Commission on Accreditation of Heulthcare Organizations (JCAH0)Illinois. U.S.A.
Calvin J. Anthony I National Community Pharmacy Association, Arlington, Virginia, U.S.A.
Edward P. Armstrong / University of Arizona, Tuc-son,Arizona, U.S.A.
Carolyn H. Asbury 1 University of Pennsylvania. Philadelphia, Pennsylvunia. U.S.A.
Iman E. Bajjoka / Henry Ford IlosIiitul, Detroit, Michigan. U S A .
Teresa Bassons Boncompte Pharmaceutical Association of Catalonia, Barcelona, Spain
Jerry L. Bauman / University of Illinois, Chicago. Illinois, U.S.A.
Diane E. Beck / Auburn Univer.sity>Auburn, Alabuma. U.S.A.
William Benda / Big Sur, Cal@niu. U.S.A.
John D. Benz 1 Americun College of Clinical Pharmacy, Kansas City, Missouri, U.S.A.
Dccna Bernholtz-Goldman / FujiiFawu Healthcare. Inc., Deerfield, Illinois, U.S.A.
Richard J. Bertin i Council on Credentialing in Pharmacy, Washington, D.C., U.S.A.
Theresa M. Bianco / Oregon Hcwlth Sciences University, Portland, Oregon. U.S.A.
Beverly L. Black / American Society of Irlealth-Sy.steni Pharmacists, Bethesda, Maryland, U.S.A.
James L. Blackburn / University qf Saskatchewun. Saskatoon. Cunadu
Deborah E. Boatwright i Veterans Aflairs M e d i d Centec San Francisco, California. U.S.A.
Joaquin Bonal de Falgas / Pharmaceutical Care Spuin Foundation, Burcelonu, Spuin
Christine M. Bond i University ofAherdeen, Aherdeen, U.K.
Joseph K. Bonnarens / Applied Heulth Outcomes, Tumpa, Florida, U.S.A.
Brent M . Booker / University at Ruffulo, Buffalo, New York, U.S.A.
Lynn Bosco i Agency for Healthcare Research and Quality, Rockville, Muryland, U.S.A.
James Buchanan 1 Tularik, Inc., South San Francisco. California, U.S.A.
Marcia L. Buck / University of Virginia Medical Center, Charlottesville, Virginia, U.S.A.
Nanette C. Bultemeicr / Oregon State Universityt Portland, Oregon, [J.S.A.
Kathleen M. Bungay The Health Institute, Boston, Mussachusetts, U.S.
A.
Naomi Burgess / Society of Hospital Pharmucists of Australia, South Melbourne, Austruliu
Judith A. Cahill / Academy of Managed Care Pharmacy, Alexandria, Virginia, U.S.A.
Karim Anton Calis / National 1nstitute.v of Health, Bethesda, Maryland, U.S.A.
William Campbrll i Univer.vity of North Carolina, Chapel Hill, North Carolina, U.S.A.
Alex A. Cardoni i The Institute of Living, Hartjwd. Connecticut, U.S.A.
Jannet M. Carmichael / VA Sierra Nevada Heukh Cure System, Reno, Nevada, U S A .
Allen Cat0 / &to Research Ltd., Durham, North Carolina, U.S.A.
Allen Cat0 lli / Cato Rescwrch Ltd., San Diego, Calijbrniu, U.S.A.
Christi Cawood Marsh / University Heulth Care Syvtem. Augustu, Georgiu. U.S.A.
Jack J. Chen i Western University of Health Sciences, Pomona. California, U.S.A.

ii

Elaine Chiquette I San Anronio Cochrane Center, San Antonio, Taus, U.S.A.
Marie A. Chisholm I University of Georgia College ofIharmucy, Athens, Georgia, U.S.A.
Thomas P. Christensen 1 North Dakota State University. Furgo, North Dakota, U.S.A.
Robert J. Cipolle I University of Minnesotu, Minneapolis, Minnesota, U.S.A.
Ana Clopes Ilospitul de Iu Stu. Creu i Sant Iau, Burcelona, Spuin
George H. Cocolas I University of North Curolina, Chupel Hill, North Carolina, U.S.A.
Marisue Cody / I4terans Affuirs Medicul Centec North Little Rock, Arkansas, U.S.A.
.Michael R. Cohen I Institute,for Sa& Medication Practices, Huntington Vulley, Pennsylvuniu, U.S.A.
Anthony Compton / St. Joseph k Hospilal of Atlanta, Atlanta, Georgiu, U.S.A.
Rachel Crafts 1 Idaho Drug Injhrmatian Service, Pocatello, Idaho, U.S.A.
Vicki S. Crane 1 Purklund Ilealth and Hospital System, Dullus, Texus, U.S.A.
Jamie Cristy Solvuy Phurmuceuticub, Atlantu, Georgiu, U.S.A.
Diane B. Crutch field I Pharmucy Consulting Cure, Knoxville, Tennessee, U.S.A.
Vaughn L. Culbcrtson 1 Iduho Stute University, Pocatello, Idaho, U.S.A.
Charles E. Daniels 1 Nalional Institutes of Health, Bethesda, Maryland, U.S.A.
Lisa E. Davis I Philudelphia College of Phurmucy, Philudelphia, Pennsylvania, U.S.A.
Robert DeChristoforo Vireo Lab Inc.. Rockville, Maryland, U.S.A.
Joseph H. Deffenhaugh American Society of Health-System Phurmucists, Bethesda, Maryland, U.S.A.
Joseph T. Di Piro University of Georgia College oj Pharmacy, Athens, Georgia, U.S.A.
Nfonso Dominguez-Cil I Hospital Univer.sitario de Salamancu, Sulumunca, Spain
Michael Dooley 1 Peter MacCallum Cancer Institute, Victoria, Austrulia
Julie A. Dopheide / University of Southern Culiforniu, Los Angeles, Cali/brnia, U.S.A.
Steven C. Ebert I Meriter IIospitul, Inc., Mudison, Wisconsin, U.S.A.
Eduardo Echarri Arrieta I Sociedud Espuiiolu de Farmucia Hospitalaria, La Coruca, Spain
Robert M. Elenbaas I Americun College of Clinical Pharmacy, Kansas City, Mimouri, U.S.A.
Mary Ensom I BCk Children k di Womenk Hospital, Vancouver, British Columbiu, Cunadu
Susan C. Fagan I University ojGeo& College of Pharmacy, Athens, Georgiu, U.S.A.
B
i
l
l C. Felkey j Auburn Univer.si& Auburn, Alabama, U.S.A.
Donald J. Filibeck 1 Mt. Carmel IIome Infusion. Columbus, Ohio, U.S.A.
Benet Fit6 Novellas I Pharmaci.st, Barcelona, Spain
Annemieke Floor-Schreudering j European Society of Clinical Phurmacy, Leiden, The Netherlands
Brent I. Fox / Auburn Univer,sity,Auburn, Alabama. U.S.A.
George E. Francisco I Univer,sityof Georgia College of Phurmucy, Athens, Georgia, U.S.A.
John A. Cans I American Pharmaceutical Association, Wushington, D.C., U.S.A.
Steven Celone / Temple University, Philudebhiu, Pennsylvunia, U.S.A.
Claire E. Cilmore I Phi1lb.s Group Oncology Communicutions, Philadelphia, Pennsylvania, U.S.A.
Joaquin Giraldez 1 Clinicu Universituriu de Nuvarru, Pamplona, Spain
Ma. Isabel Crespo Gonzalez I Urbanizucibn Monleclaro, Madrid, Spain
Kathryn L. Grant I University of Arizona, Tucson, Arizona, U.S.A.
Rafael Guayta Escolies I General Directorate of Public Heallh, Autonomous Govern of Cutulonia, Catalonia. Spain
Dave Hachey I Idaho State University, Pocutello, Idaho, U.S.A.
Cindy W.Hamilton 1 Hamilton House, Virginiu Beach, Virginia, U.S.A.
David Hawkins 1 Mercer University, Atlantu, Georgiu, U.S.A.
Dean G. Haxby I Oregon State University, Portland, Oregon, U.S.A.
Yechiel Hckstcr 1 University Medical Centre, N i j m e n , The Nelherlands
Mary Hemming I Therapeutic Guidelines Limited, North Melbourne, Austrulia
Catherine A. Heyncman / Idaho State Universily, Pocalello. Idaho, U.S.A.
Teresa J. Hudson I Veterans AJairs Medical Center, North Little Rock, Arkunsrrv, U.S.A.,
Antonio ldoate I Clinica Universitaria de Navarra, Pamplona, Spain

iii

John Jackson 1 Integrated Pharmucy Services, Kctoria, Austruliu

Judith Jacobi 1 Methodist IIo.spital/Clarian Health, Indiunupoli,s, Indiana, U.S.A.
Kevin M. Jarvis I Biocentric, Inc., Berkley, Michigan, U.S.A.
Tommy Johnson i University of Georgia College of Pharmucy, Athens, Georgiu, U.S.A.
Joan Kapusnik-Uner First DatuBank, Inc., San Bruno, Culifornia, U.S.A.
Yasmin Khaliq I Rochestec Minnesota, U.S.A.
Arthur H. Kibbe 1 Wilkes Universit)z Wilkes-Barre, Pennsylvuniu, U.S.A.
Daren I,. Knocll I The Ohio State Univer,si& Columbus, Ohio, U.S.A.
Jill M. Kolcsar I University of Wi,sconsin, Madison, Wuconsin, U.S.A.
Sheldon X. Kong ,! Merck & Co. Inc., Whitehouse Station, New Jersey, U.S.A.
Joan K. Korth-Bradley 1 JR Ashtin Group lnc,, Canton, Michigan, U.S.A.
Edward P. Krenzelok 1 Children k Hospital of' Pittsburgh, Pittsburgh, Pennsylvania, U.S.A.
Patricia Dowlcy Kroboth University of Pittsburgh, Pittsbutgh, Pennsylvania, U.S.A.
Sumn E. Kucukarslan I Henly Ford Hospital, Detroit. Michigan, U.S.A.
Peggy C . Kuehl ,! American College of Clinical Phurmacy, Kansas City, Missouri, U.S.A.
Mae Kwong Americun Society of Health-Sy,stem Pharmacists, Bethesda, Maryland, U.S.A.
Carlos Lacasa 1 Clinica Universituriu de Nuvurra, Pumplona, Spain
Y.W. Francis Lam I University of Taus Heulth Science Center at San Antonio, San Antonio, Taus, U.S.A.
Grace D. Lamsrm 1 University of Pittsbuqh School of Phurmacy. Pittsburgh, Pennsylvuniu, U.S.A.
Kimberly J. La Pointe Childrenk Hospital of The King? Daughters, Norfolk, Krginia, U.S.A.
Beth A. Lcshcr i Humilton House, Krginia Beuch, Krginia, U S A .
Donald E. Letendre / American Society of Heulth-System Pharmacists, Bethesda, Maryland, U.S.A.
Arthur G. Lipman / University of Utah, Salt Luke City, Utah, U.S.A.
Elizabeth Tracie Long 1 ISPOR--Internutionul Society for Pharmacoeconomics and Outcomes Reseurch, hwrenceville,
New Jersey, U.S.A.
Neil J. MacKinnon Dalhousie Universiy, HuIifa, Nova Scotia, Cunudu
Robert L. Maher, Jr. ,! Duqume Univer.sity, Pittsburgh, Pennsylvania, U.S.A.
Robert A. Malone I National Community Pharmucy Associution, Arlington, Krginia, U.S.A.
Patrick M. iMalone 1 Creighton University, Omahu, Nebrusku, U.S.A.
Henri R. Manasse, Jr. American Society oj Heulth-System Phurmacists, Bethesda, Marylund, U.S.A.
Henar Martinez Sanz I Sociedud Espaiiolu de Farmucia Hospitularia, Mudrid, Spain
Pilar Mas Lombarte 1 Fundacibn Hospitul-Asil de Granollers, Granollers, Spain
Gary R. Mabke I Univer.sity of PittshuEh, Pittsburgh, Pennsylvania, U.S.A.
J. Russell May / Medicul College of Georgiu Hospitals & Clinics, Augustu, Georgiu. U.S.A.
Theresa A. Mays 1 Cancer Therapy and Reseutrh Center, San Antonio, Taus, U.S.A.
William McLean 1 Les Consultants Pharmuceutiques de I 'Outaouuis, Cantley. Quebec, Canada
William A. Miller I University of Iowa, lowu City, Iowa, U.S.A.
David 1. Min / Univer-sityof Iowa, Iowa City, Iowa, U.S.A.
Josi-Bruno Monioro-Ronsano / Hospital Generul VuN d 'Hebron, Barcelona, Spain
Phylliss Morct 1 American Society of Consultant Pharmaci,sts, Alaundriu, Kqinia, U.S.A.
Walter J. Morrison Provider Payment Solution, Inc,, Little Rock, Arkansas, U.S.A.
Gene D. Morse 1 Universdy ut Buflulo, BuJaIo, New York. U.S.A.
Pat Murray 1 Royal Edinbutgh Hospitul, Edinburgh, U.K.
Milap C. Nahata i The Ohio Stale Univer,si& Columbus, Ohio, U.S.A.
Gloria J. Nichols-English 1 University of Georgia College of Phurmacy, Athens, Georgia, U.S.A.
Edward H. O'Neil I Western University, Pomona, California, U.S.A.
Ana Ortega 1 Clinica Universitaria de Navarra, Pamplona, Spain
MariaJosb Oiero Hospitul Universiturio de Salamanca. Salumuncu, Spain
Thomas W. Paton / University of Toronto, Toronto, Onturio, Canudu
Stephen H. Paul 1 Temple University, Philudelphiu, Pennsylvuniu, U.S.A.

iv

Richard P. Penna / American Association of Co1lege.s of PhurmaLy, Alexandria, Virginia, U.S.A.

Carmen Permanyer Mum6 i Pharmaceutical Association of Catalonia, Barcelona. Spain
Matthew Pern I11 i University of Georgia College of Pharmacy, Athens. Georgia. U.S.A.
Vanita K. Pindolia / Henly Ford Health .+stem, Detroit, Michigun, U.S.A.
Stephen C. Piscitclli / Mrco Lab Inc.. Rockville, Maryland, U.S.A.
Sylvie Poirier / Regie Regionale de la Sunte et de.9 Service.s Sociuux Monteregis Quebec, Cunuda
Therese 1. Poirier / Duyucme University, Pittsburgh, Pennsylvuniu, U.S.A.
Samuel M. Poloyac / University of Pittsburgh, Pittsburgh. Pcc.nsylvuniu, U.S.A.
Jeff Poston I Canudian Pharmacists Association, Ottawa, Onturio. Canada
Leigh Ann Ramsey / Univer.sity of Missi.ssippi. Jackson, Mississippi. U.SA.
Teresa Rcqucna Caturla / Ifospitul Principede Asturias , Madrid, Spain
Renee E Robinson / The Ohio State Univer.sity, Columbus. Ohio, U.SA.
Chip Rohison BeneScript Services, Incc., Norcross, Georgia U.S.A.
David S. Roffman / University qf Maryland. Baltimore, Maryland, U.S.A.
Brendao S. ROSS/ Department of kteruns Affuirs Medical CenteK Juckson, Mississippi, U.S.A.
Simone Rossi / Austrulian Medicines IIundbook Pty Ltd., Adelaide, Austrulia
Myrella T. Roy / The Ottuwu Hospital, Ottawu, Ontario, Cunuda
John RUSSO,
Jr. / The Medical Communicutions Resource, Mahwah, New Jersey, U S A .
Melody Ryan / Univer.sity oJ Kentucb, Lexington, Kentucb, U.S.A.
Rosalie Sagraves / University of Illinois, chicugo, Illinois, U.S.A.
Richard T. Scheife / American College of Clinical Pharmacy. Boston. Massachusetts. U.S.A.
Lauren Schlcssclman / Niantic, Connecticut. U.S.A.
Patricia H. Schoch I Denver VA Mc.dical Center. Denvec Colorado. U.S.A.
Jon C. Schommer / University of Minnesotu. Minneapolis, Minnesotu, U.S.A.
Terry L. Schwinghammer / University of Pittshuqh School qf Phurmucy, Pittsburgh, Pennsylvunia, U.S.A.
Gayle Nicholas Scott / Medical Communications and Consulting, Che.sapeake, Mrginia. U.S.A.
Leon Shargel / Eon Labs Manujacturing Inc., Jmmdton, New York, (J.S.A.
Marjorie A Shaw Phillips / Medical College of Georgia Hospitab and Clinics, Augusta,
and University of Georgiu College ojPharmacy, Athens, Georgiu. U.S.A.
Kenneth 1. Shine / Institute of Medicine, Wushington. Di.strict ojColumbiu, U.S.A.
Ingrid S. Sketris / Dalhousie University. Hulifiu, Novu Scotiu, Cunudu
Betsy L. Sleath i University of North Curolina, Chupel Hill, North Carolina, U.S.A.
William E. Smith / Virginia Commonweulth University. Richmond, Mrginia, US.A.
Patrick E Smith / 1Jniversity at Bujlizlo, Buffulo. New b r k , U.S.A.
Mary ROSSSouthworth / (Jniver.sityqf Illinois, Chicago, Illinois, U.SA.
Lara E. Storms I M n i a Commonwealth University School of Pharmacy, Richmond. Virginia, U.S.A.
Lynda Sutton / Cato Research Ltd., Durham, North Carolina, U.S.A.
C. Richard Talley 1 American Society of Health-System Pharmacists, Bethesda. Maryland, U.S.A.
Carl E. Trinca / We.stern University, Pomona, Califbrnia, U.S.A.
Patricc Trouillcr / University Hospital of Crenoble, Grenoble, France
Carl J. Tullio 1 Pfizer. Inc., Yorktown, Mrginia, U S A .
Kimbcrly Vcrnachio / Cunton, Georgia. U.S.A.
Peter H. Vlasscs i American Council on Pharmaceutical Education, Chicago, Illinois. U.S.A.
Jeffrey W. Wadclin / American Council on Pharmaceutical Education. Chicago. Il1inoi.s. U.S.A.
Margaret C. Watson / University qf Aberdeen. Aberdeen, U.K.
Timothy Wcbstcr / American Society of Consultant Pharmaci.st.s, Alexandria, Mrginia, U.S.A.
Barbara G. Wclls / Univecsity of Missi.s.sippi, Univer.sity, Missi.ssippi, U.S.A.
Albert 1. Wertheimer / Temple Univemity, Philudelphiu, Pennsylvania. U.S.A.
Roger L. Williams / U.S. Pharmucopeiu, Rockville, Maryland, U.S.A.
Harold H.Wolf / University of Utah. Salt Lake City, Utah, U.S.A.

Carol Wolfe 1 American Society qr Health-System Pharmaci.st.s,Bethesda, Maryland, U.S.A.

Andrew R.C. YU / U.S. Food and Drug Administration, Rockville, Maryland, U.S.A.
Woodie M. Zachry 111 / University of Arizona, Tucson. Arizona, U.S.A.
Dawn C. Zarembski / American C'ouncil on Pharmaceuticul Education, Chicago, Illinois, U.S.A.
Barbara Zarowitz / Henry Ford Health Syslcm. gingham Farms, Michigan, U.S.A.
David S. Ziska Applied Health Outcomes, Tumpu, Florida, U.S.A.

Academia. Clinical Pharmacy Careers in / Iliane E. Beck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

I
Academy of Managed Care Pharmacy / Judith A . Cahill . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6
ACPE Standards 2000 / J ~ f f r e yW. Wadelin and Peter H . Vlasses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8
i0
Adherence to Pharmaceutical Care / Gloria J . Nichols-English and Sylvie Poirier . . . . . . . . . . . . . . . . . . . . . . . .
Adverse Drug Reactions / There.se I. Poirier and Robert L. Maker, Jr.
.....................
23
Agency for Healthcare Research and Quality I William Cumphell, Betsy
Lynn Bosco . . . . . . . . . . . . 35
Ambulatory CareRrirnary Care, Clinical Pharmacy Careers in / Dave Huchey . . . . . . . . . . . . . . . .
American College of Clinical Pharmacy (ACCP) I Robert M . Elenbaus . . . . . . . . . . . . . . . . . . . . .
American Council on Pharmaceutical Education I Dawn 6. Zaremhski and Pcter H . Vlasses . . . . . . . . . . . . . . . . 45
American Journul qf Health-System Pharmacy (ASHP) I C. Iiichard Talley . . . . . . . . . . . . . . . . . . . . . . . . . . . .
48
American Journal of PharmaccJutical Education I Grorge H . Cocolas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
50
American Pharmaceutical Association / John A . Cans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
51
American Society or Consultant Pharmacis
Timothy Wehster and Phylliss Moret . . . . . . . . . . . . . . . . . . . . . .
53
American Society of Health-System Pharm
. (ASHP) / C. Richard Talley . . . . .
56
Antibiotic Rotation I Steven Gelonc . .
..................................................
58
63
Anticoagulation Clinical Pharmacy Practice / Patricia H . Schoch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
71
Association of Faculties of Pharmacy of Canada I James L . Bluckburn . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
73
Australian Adverse Drug Reaction Advisory Committee / Christopher P . Alderman . . . . . . . . . . . . . . . . . . . . . .
Australian Medicines Handbook / Simone Rossi . . . . . . . . . . . . . . . . . . . . . . . . . .
Best-Practices Documents (ASHP) I .I 0.wph H . Deflc,nbuugh . . . . . . . . . . . . . . . . . .
Biopharmaceutics / Leon Shargel and Andrew B.C. Yu . . . . . . . . . . . . . . . . . . . . .
103
Board of Pharmaccutical Specialties / Barbara G. Wells and Richard J . Bertin . . . . . . . . . . . . . . . . . . . . . . . . .
Bone Marrow Transplant Pharmacy Practice 1 Vanita K . Pindolia . . . . . . . . . . . . . . . . . . . . . . . . . .
Canadian Hospital Pharmacy Residency Board / I7iomas W. Puton . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
111
Canadian Pharmacists AssociationJAssociation des Pharmaciens du Canada I Jeff Poston
Cardiac ArresUEmergency Pharmacy Services / David S . Rofmun . . . . . . . . . . . . . . .
Cardiology, Clinical Pharmacy Practice in I Mary Ross Southworth and Jerry L. Bauman . . . . . . . . . . . . . . . . . 119
127
Clinical Evaluation of Drugs / A l l m Cato, Lyndu Sutton and Allen Cato Ill . . . . . . . . . . . . . . . . . . . . . . . . . . .
139
Clinical Laboratory Improvement Amendments of 1988 / Thomas P . Christensen . . . . . . . . . . . . . . . . . . . . . . .
Clinical Pharmacist as Principal Investigator (ACCP) / American College of Clinical Phurmucy . . . . . . . . . . . . 144
Clinical Pharmacist, Evaluation of a (ACCP) / American College of Clinical Pharmacy . . . . . . . . . . . . . . . . . . 154
161
Clinical Pharmacokinetics Specialty Practice / Mary Ensom and Y.W. Francis Lam . . . . . . . . . . . . . . . . . . . . . .
Clinical Pharmacy Practice Guidelines (Society of Hospital Pharmacists of Australia) / Michael Dooley . . . . . . . 170
174
Clinical Pharmacy Scientist I Putriciu Dowley Krohoth, Snmuel M . Poloyac and Cavy R. Matzke . . . .
Cochrane Library, The / Elaine Chiquette . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
181
Collaborative Drug Therapy Management by Pharmacists (ACCP) / AmcJrican College oJ Clinical Pharmacy . . . 188
Collaborative Practice Agreements (CollabordtiVe Drug Therapy Management) / Jannet M . Curmichael . . . . . . . 199
207
College of Psychiatric and Neurologic Pharmacists I Alct A . Cardoni . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
210
Commission to Implement Change in Pharmacy Education, AACP / Harold H . W o u . . . . . . . . . . . . . . . . . . . .

viii
Computer Software for Clinical Pharmacy Services I Bill C. Felkey m d Brent I . Fox . . . .
Crcdentialing in Pharmacy I Richard J . Bertin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Critical Care Pharmacy Practice I Judith Jacobi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Critical Care Pharmacy Services (ACCP) I American College of Clinical Pliarmacy . . . .
Cytochrome P450 I David 1. Mia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.........................
Department of Health and Human Scrvices I Lauren Schlesselinan . . .
Diabetes Care, Pharmacy Practice in I Tommy Johnson . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
..
.................
Dietary Supplement Health and Education Act I Chyle Nicholas Scott
Dircctions for Clinical Practice in Pharmacy (Hilton Head Conference) I Mae Kwnng . . . . . . . . . . . . . . . . . . . .
Disease Management I Leigh Ann h'amsey and Hrendarz S. Ross . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Doctor of Pharmacy I GeorgP B. Francisco . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Drug Enforcement Agency I Claire E. Cilmoi-e . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Drug History I Christi Cuwood Marsh . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Drug Information Pharmacy Practicc I Patrick M . Malone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Drug Samples I Nanette C. Sultemeier and D(.an C. Haxby . . . .
...........................
Economic Evaluations of Clinical Pharmacy Services (ACCP) / A
ollege ($Clinical Pharmarj . . . . . .
Electronic Prescribing I Woodie M . Zachry I11 and Edward P . Armstrong . . . . . . . . .
............
Ethical Issues in Clinical Pharmacy I Teresa K ~ ~ q u e nCaturla
a
....................................
Ethical Issues Related to Clinical Pharmacy Research (ACCP) / American College of Clinical Pharmacy . . . . . .
European Society of Clinical Pharmacy I Annemieke Floor-Schreudering and Yechiel Hekster . . . . . . . . . . . . . .
Evidence Based Practice I Christine M . Bond and Margaret C. Watson . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
I-kllowships in Pharmacy I Joseph 7. DiPiro . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
First DataBank, Inc . I Joan Kapusnik-Uner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Formulary Systems I J . Russell May . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Gene Therapy I Daren L. Knoell and Jill M . Kolesar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.........................
Generic Drugs and Generic Equivalency I Arthur H . Kibhe . . . . . . . . . .
Government: Clinical Pharmacy Careers in / Stephen C. Piscitelli and Robert DeChristoforo . . . . . . . . . . . . . . .
Health Care Systems: Outside the linited States I Albert I . Wertheimer and Sheldon X . Kong . . . . . . . . . . . . . .
Health Care Systems: Within the Unitcd States I Henri R . Marzasse, J r. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hcalth Scrvices Research I Teresa J . Hudson and Marisue Cody . . . . . . . . . . . . . . . .
Hcalth Status Assessment I Kathleen M . Buizcgay . . . . . . . . . . . . . . . . . . . . . . . . . . .
Health-Systems, Clinical Pharmacy Careers in I William E . Smith . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Healthy People 2010: Objectives for Improving Health / Carl J . Tullio . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Home Care, Clinical Pharmacy Careers in I Donald J . Filibeck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Home Care Pharmacy Practice (Spain) I Ana Clopes . . .
...............
.
.........................
Hospice and Palliative Care I Arthur G. Lipman . . . . . .
Hospital Pharmacy Practice in Spain I Joaquiiz Ciruldez, Ana Ortega, Antonio Idoate, Azzicena Aldaz
and Carlo.s Lacasa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hyperlipidemia Pharmacy Practicc I Theresa M . Bianco . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Infectious Diseases Specialty Pharmacy Practice I Steven C. Ebert . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Institute for Safe Medication Practices I Michael R . Cohen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
I Maria-Jose' Otero and Alfonso Dominguez-Gil . . . . . . . . . . . . .
Institute for Safe Medication Practices-Spain
Institute of Medicine I Kenneth 1. Shine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Integrative Medicine I Kathryn I . Grant and William Bendu . .
.....
..
...
.
International Pharmaceutical Abstracts (ASHP) I Carol Wolfe . .
...........................
International Society for Pharmacoeconomics and Outcomes Research I Elizabeth Trucie Long . . . . . . .
.
Janus Commission (AACP) I Richard P . Penna . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Joint Commission for the Accreditation of Health-Care Organizations I Kathryn T. Andrusko-Furphy . .
Joint Commission of Pharmacy Practitioners (JCPP) I Robert M . Elenhaas . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Long-Term Care, Clinical Pharmacy Careers in / Diane B . Crutchfield . . . . . . . . . . . . . . . . . . . . . . .
Managed Care, Clinical Pharmacy Careers in I Barbara Zarowitz . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Managed Care Pharmacy Practice I Beverly L. Black . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Medicaid and Medicare Pharmaceutical Programs / Albert I . Wertheimer and Stephen H . Paul . . . . . . . . . . . . . .
Medical Communications, Clinical Pharmacy Careers in / Lara E . Storms and Cindy W. Hamilton . . . . . . . . . . .

246
251
256
260
265
267
276

295
301
326
330
335
344
348
355
358
362
367
379
385
389
397

428
432
435
439
441
453
461
469
476
478
480
4x2
481
488
491
496
501
506
512
519

iX

Medical Information, Industry-Based I Deena Rcrtzlzolti-~;oldman . . . . . . . . . . . . . . . . . . . . . . . . .

Medicarc Benefits and Improvement Act of 2000 for Outpatient Immunosuppressive Agents I
Mark A. Cliislzolm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Medication Assistance Programs, Pharmaceutical Company-Sponsored I Marie A. Chisholm . . . . . . . . . . . . . . .
Medication Errors and Advcrse Drug Events Prevention I Vicki S. Crane . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Medication Use Evaluation I Marjorie A Shaw Phillips . . . . . . . . . . . . . . . . . . . . . . . .
.............
Medication lJsc for Unapproved Indications I Kimberly J. La Pointe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Millis Commission-Study Coinmission on Pharmacy I William A. Miller . . . . . . . . . . . . . . . . .
National Childhood Vaccine Injury Act of I986 I Rachel CraJs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.
National Conimittce for Quality Assurance I Kevin M. Jarvis . . . . . . . . . . . . . . . . . . . . . . . . . . .
National Community Pharmacists Association I Calvin J . Anthony and Robcvt A. Malone . . . . . . . . . . . . . . . . .
National Institute for Standards in Pharmacist Crcdentialing I Wulter J. Morri.son . . . . . . . . . . . . . . . . . . . . . . .
...............
National Institutes of Health I Karin7 A n f o n C d i s and Charles E. Daniels . . . . . . .
National 1.ibrary of Medicine I Joan K. Korlh-Bradley . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.........
Neurology Spccialty Pharmacy Practice I Susaii C. Fagun and Melody Ryan . . . . .
Nontraditional Pharm.D. Programs I Vaughn L. Culbertson and Catherine A . Heynem
Nutraceuticals and Functional Foods I John Kusso, Jr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Oddis. Joscph A. I C. Richard Talley . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......
Oncology Spccialty Pharmacy Practice I Lisa E. Davis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Orphan Drugs I Carolyn H. AsburT). . . . . . . . . .
. .
...
.......................
Pain Management, Pharmacy Practice in I Theresa A. Mays . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.................
Patient EducationICounseling I Mattlzew Perri 1II and Jamie Cristy . . . . . . . . . . .
Patient Satisfaction I Jon C. Schomnzer and Suzan E. Kuc~ulcurslaii . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Pediatric Dosing and Dosagc l k m s I /iosalie Sugmves . . . . . . . . . . . . . . . . . . . . . . . . . .
Pediatric Pharmacy Specialty Practice I Murc,ia L. Buck . . . . . . . . . . . . . . . . . . . . . . . . . .
Pcw Health Professions Commission Reports I Carl E. Trinca and Edward H. O'Neil . . . . .
Pharmaccutical Benefits Scheme (Australia) I John Jackson .
........................
........................
Pharmaceutical Care I ' k r y L. Schwinghammer and Grace I).
Pharmaccutical Care Spain Foundation I Joaquin Ronal de Fa1
...
...............
Pharmaccutical Outcomes I Neil J. MacKinnon and Ingrid S . Sketris . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Pharmacicns Sans FrontiCrcs (Pharmacists without Borders) I Myrella T. R o y . . . . .
...........
Pharmacist Managed Vaccination Programs I David S. Ziska and Joseph K. Bonnarens . . . . . . . . . . . . . . . . . . .
Pharmacist Prescribing I Dc4~orahE. Boatwrigkt . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Phai-macotherapy, The Journal of Human Pliarmacology and Drug Therapy I Richard T.ScheJfe . . .
Pliarnzac~othera~)l,y
SelJAsse.s,snzc~ntProgi-unz (ACCP) I John D. Renz . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Pharmacothcrapy Spccialists, Practice Guidelines for (ACCP) I
Anzc~ricaizC o l l ~ g eof Clinical Pharmtic,y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Pharmacotherapy Specialty Practice I Jack ./. Chen . . . . .
.....
.........
.................................
Pharmacovigilence I Jamm Buclzanan . . . . . . . . . . . . . .
Pharmacy Benefit Managcmcnt I Chip Robison and Kimberly Vernachio .
. .
Pharmacy i n thc 21st Ccntury I Mae Kwong . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Placebo Effects I Renee F. Kohinsori und Milap C. Nahafa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Poison Inlormation Pharmacy Practice I Edward P. Krenzelok . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Policy Documents and Laws That Guide Clinical Pharmacy Practice in Spain I
Eduar-do Echarri Arrirta and Henar Marfinez Sanz . . . . . .
...
.....................
Post-Marketing Surveillancc I Beth A. Lrsher . . . . . . . . . . . .
...........................
Presrriptiom / o r Health: Thc Lowy Rcport I William McLean
...
.......
........
Preventivc Medicine I Trwsu Bassoris Boncompte,Carmen Permanyer Munne', Benet Fite' Novellas
and f<ufuel Guayta Escolies . . . . . . . . . . . . .
................................
......
Primary Care, Clinical Pharmacy Services in (ACCP) I American College qf'Clinica1 Pharmacy . . . . . . . . . . . .
.
Professional Associations, Clinical Pharmacy Careers in I P e g g y G. Kuehl . . . . . . . . . . . . . . . . . . .
Psychiatric Pharmacy Specialty Practice I Julie A. Dupheide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Quality Assurance of Clinical Pharmacy Practice I Pilar Mas Lomharte . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Residencies I Donald E. Letendre . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

530
531
533
545

550
559
564
568
572
575
580
584

609
611
627
635
647
65 1

688
692
698
701
707
710

726
728
732
736
741
749
752
757
779
785
791
794
801
818
822
827
837

Role of the Clinical Pharmacist in Clinical Trials (Spain) I Josi-Bruno Montoro-Konsano . , . . . . . . . . . . . . . , .

Society of Hospital Pharmacists of Australia, The I Naomi Burgess . .
...................
Spanish Society of Hospital Pharmacy I Ma. Isabel Crespo Gonznlez . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Therapeutic Guidelines Australia I Mary Hemming . . . . . . . . . . . . . . . . . . . . . . . . .
.............
Therapeutic Interchange I Anthony Compton . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . .
Therapeutic Interchange, Guidelines (ACCP) I American College of Clinical Pharmacy .
............
Transplantation Pharmacy Practicc I Onan E. Bajoku and Marwan S. Abouljoud . . . . . . . . . . . . . . . . . . . . . . .
Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans I Yasmin Khaliq
UK Clinical Pharmacy Association I Pat Murray . .
.................
...................
1Jnited States Pharrnacopeia I Roger L. Williams . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Universal Precautions and Post-exposure Prophylaxis for HIV I Brent M. Booker, Patrick F. Smith
andGenrD.Morse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Walton, Charlcs I David Huwkins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Weaver, Lawrence I Robert .I. Cipolle
.........
.....................................
World Health Organization I Putrice Trouiller . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
World Health Organization Essential Drug List / Palrice Trouiller . .
.........._____....

843
85 1
854
857
860
864
869
876
883
886
89 1
899
902
904
...
908

Everyone reading this foreword already knows that clinical pharmacy is evidence-based. Those in the field rely
heavily on therapeutics textbooks, drug information compendia, journal articles, and thc World Wide Web as
critical sources of information and knowledge to guide their patient care and research decisions. So what can
a resource like the Encyclopedia o j Clinical Pharmacy add to the growing (and some might say already overcrowded) library of professional literature?
This encyclopedia is not intended to be a textbook of therapeutics or a compendium of drug information.
Rather, its goal is to document information about key people, events, publications, legislation, regulations, and the
myriad of things other than therapeutics per se that shape what clinical pharmacists do, why thcy do it, and how
they do it. It was this opportunity that convinced the American College of Clinical Pharmacy and the American
Society of Health-System Pharmacists to partner with Marcel Dekker, Tnc. in this unique project.
Although efforts to publish the Encyclopedia of Clinical Pharmacy began in early 1999, its true origins lie
in the pioneering work of visionary pharmacists like Donald Brodie, Donald Francke, Paul Parker, Harvcy A. K.
Whitney, and others in the 1950s, ' ~ O S ,and '70s. They foresaw the increasing complexity of pharmacotherapy, the
problems or medication-related morbidity and mortality, and the impact that clinically empowered pharmacists
have on assuring safe and effective pharmaceutical care for patients. The Encyclopedia of Clinical Pharmacy-in
print and online-is designed to be a dynamic resource that will expand as future events unfurl and as time allows
a more complete documentation of important past contributions and contributors. Thus, as clinical pharmacy continues to evolve, so will the Encyclopedia.
Robert M. Elenbaas, Pharm.D., FCCP
Executive Director
American C o l l e g ~qf Clinical Pharmacy
Kansas City, Missouri, U.S.A.

Henri R. Manasse, Jr., Ph.D., Sc.D.

Executive Vice President and Chief Exmitive Officer
American Society qf Health-System Pharmacists
Bethesda, Maryland, U.S.A.

The term clinical pharmacy has come to describe a wide range of pharmacy practices that occur in a variety of
settings, including health-systems, community pharmacies, clinics, pharmaceutical industry, and government
agencies. Clinical Pharmacy incorporates the patient-oriented practices of pharmaceutical care as well as drug policy management, research, education, and many other aspects within the field. As the scope of clinical pharmacy
has grown, it has been less easy to capture in a simple definition. The range of topics included in the Encyclopedia
o j Clinicul Phnrmacy attest to the complexity and expansion of the clinical pharmacy practice.
The Encyclopedia of Clinical Pharmacy is a valuable resource for todays clinical pharmacist and pharmacotherapist. Practitioners require a large set of information on diverse topics to effectively conduct their practices.
While some of this information can be obtained from drug information compendia, therapeutics textbooks, and
primary literature reports, these sources do not thoroughly address the different dimensions of knowledge and
information required by clinical pharmacists. The Encyclopedia o j Clinical Pharmacy assembles information for
practicing clinical pharmacists and students not found in disease-oriented or drug-oriented resources, and provides
information and insights to topics and issues that relate to clinical pharmacy practice.
All entries in the Encyclopedia have been written by experts in their fields and reviewed by appropriate subject matter authorities. Categories of clinical pharmacy-related topics included in the Encyclopedia are:
0
0
8

0
0
0

Important reports, position papers, and consensus statements.

Clinical pharmacy practices and models of health service delivery.
State-of-the-art practices in selccted, rapidly changing areas of pharmaceutical and medical sciences, or
allied fields.
Federal and svate agencies and pharmacy-related organizations.
Relevant legal issues and court decisions.
Processes, methods, and guidelines impacting clinical researchers.
Biographies oP leaders and innovators in clinical pharmacy.
Educational and training programs.

The Encyclopedia is available in a printed text and an online version. The online version includes everything
in the print version while also providing the convenience of a keyword search engine. New articles and revised articles will be digitally posted quarterly and available to all subscribers of the electronic version as soon as available.
Although the content will initially pard lel the print version, unique electronic enhancements will be available on
the online version.
The intended audience for the Encyclopedia is clinical pharmacists and pharmacy students throughout the
lopediu should become an essential resource for libraries and drug information centers as well as
for personal libraries. The Encyclopedia will also be of interest to other health care practitioners and students who
wish to learn about clinical pharmacy practice. The Encyclopedia S international Editorial Advisory Board represents the United States, Canada, Australia, the United Kingdom, Germany, Spain, Switzerland, and Japan.
This project was begun with the intent of representing clinical practice expertise emanating from two major
organizations, the American College of Clinical Pharmacy (ACCP) and the American Society of Health-System
Pharmacists (ASHP). Robert Elenbaas from ACCP and Richard Taliey from ASHP have been particularly helpful in
marshalling the expertise within their organizations to contribute to the Encyclopedia. The completion of this project was only possible through the sound advice and contributions of the Encyclopedia of Clinicul Pharmucy s international Editorial Advisory Board, contributors, and the competent and diligent efforts of the staffat Marcel Dekker,
Inc. In particular, the efforts of Carolyn Hall, Ellen Lichtenstein, and Alison Cohen have been much appreciated.
Joseph T. DiPiro

Encyclopedia of
Clinical Pharmacy

PROFESSIONAL DEVELOPMENT

Auburn University, Auburn, Alabama, U.S.A.

I
If you are contemplating a pharmacy practice career in
academia, this may stem from the intellectual and cultural stimulation and the variety of interesting and eager
people that you encountered while in college. However, there are many aspects of this career path that
are not readily apparent. The goal of this article is to
expand your perspectives about clinical pharmacy academia so that you are more informed about it as a
carecr opportunity. Specifically, this article provides
an overview of the clinical pharmacy careers in academia, insight into important issues in academia, and
recommendations for making informed decisions about
carecr options.

Academic positions are often cited as being cither a

tenure-track or a nontenure-truck and arc often available
to clinical pharmacy faculty at cither a pharmacy or a
medical school. A tenure-track position is one that
requires an individual to successfully demonstrate scholarly accomplishrncnts within the initial six years of
employment, and in return, the university guarantees
lifetime employment unless the institution falls into financial exigency or the faculty member exhibits misconduct. With a nontenure-track position, the faculty member
must also dcmonstrate some level of scholarly accomplishment, but there is more flexibility in the window of
time during which this occurs. Although the university
does not commit itself to lifetime employment of individuals in nontenurc positions, it does provide a contract
that conveys a commitment of employment for a given
period of time and the contract is usually renewable at
the end of each period. Individuals who cnjoy teaching
but who do not desire scholarshiphesearch responsibilities are encouraged to seek an adjunct or affiliate cliEncylopediu of Clinical Phurmtrcy
001: 10.108 IIE-ECP 120006174
Copyright 8 2003 by Marcel Dckkcr, Inc. All rights reserved

nical faculty appointment with a ncarby pharmacy and/or

medical school.
Activities and Overview of
Most full-time clinical pharmacy faculty positions require
the individual to balance and accomplish responsibilities
related to four missions: 1 ) teaching, 2) scholarshiph-esearch, 3) service, and 4) patient care/practice. Although
all faculty must make some level of contributions to each
of these responsibilities, many institutions expect faculty
to cxcel in only one or two of these four missions. There
are several important career options that must be
considered in ordcr to successfully balance and achieve
thcse responsibilities. First, an individual pursuing an
academic career must decide upon either a tenure- or
nontenurc-track option. Sccond, because it is difficult to
be accomplished in all four of these areas, there are
primarily two types of tenure-track clinical faculty position models now offered by pharmacy
Individuals who assume the practitioner-educator model
have equal responsibility for patient care/teaching and
rcsearch/scholarship. Those who fulfill the researcher1
educator model spend the majority of their time in
research and teaching with much less time devoted to
patient care. A nontenure-track position is similar to the
practitioncr-educator model but, at some institutions thcy
have less time devoted to research. The following sections
provide insight into issues and factors to consider when
contemplating either a full-time, college-based tenure- or
nontenure-track position.
~ c a ~ ein~ Transiti
i a
Higher education is currently undergoing rigorous financial restriction, external demands for accountability,
and self-scrutiny . Therefore, any future academic career
will likely be different than that of the faculty you had in
college. For example, those entering academic clinical
I

pharmacy today are encountering changes in the tenure

system, a different reward system, and continued evolution of academic clinical pharmacy.

Changes in the tenure system

In the early 1900s the tenure system was established so
that faculty would have the academic freedom to express
their thoughts without fear of dismissal.[31 Due to statutory repeal of the mandatory retirement age and financial restrictions in higher education, many institutions
are finding tenure limits their flexibility in responding to
fluctuations in admissions to different degree program^.'^]
Advocates believe tenure is necessary since it provides a
healthy environment that encourages new ideas; individuals can say what they want and be protected from dismissal.['] Opponents believe it protects the incompetent
and reduces the flexibility institutions need to be responsive to new demands such as limited financial resources and accountability.
At most institutions, the tenure system provides new
assistant professors a time span of approximately six years
in which to demonstrate achievement in teaching, service,
practice. and sch~larship/research.[~]
After this window of
time, the faculty decides whether to grant tenure. The
granting of tenure implies a guaranteed position within
the university unless there is financial exigency or the
faculty member is found guilty of misconduct.
When contemplating the tenure- versus nontenuretrack alternatives, the individual should weigh the benefit
of academic freedom with the difficulty, stress, and
anxiety that many academicians encounter when trying to
accomplish promotion and tenure criteria within a sixyear window. Because clinical pharmacy faculty members
have to establish a practice in addition to teaching, scholarshiphesearch. and service, these time constraints can be
particularly stressful and inflexible.@]To facilitate longterm success, some institutions are offering clinical faculty members the opportunity to begin on a nontenuretrack and move to the tenure track once their practice and
research abilities are established.

Changes in the reward system

In the early 1600s when the first colleges were established
in the United States. the primary college mission of the
faculty was teaching.[71 However, since then our universities have added service as a second mission in order to
meet a need of society for practical assistance in everyday
living, and research as a third mission due to the influence

Academia, Clinical Pharmacy Careers in

of higher education from Germany. This research mission

requires faculty to generate new knowledge rather than
just convey knowledge.[71 Institutions with medical and
health-related profession educational programs
also have
practice/patient care as an extension of their service or
outreach mission.
Unfortunately, by the mid- 1900s the faculty reward
system, even in institutions with no graduate programs,
had evolved to one in which decisions about faculty
promotions were largely based only on the individuals
research and publication record.[71 The effectiveness of
one's teaching was given little, if any consideration at the
time of promotions.
In 1990, Boyer called for academia to move beyond this
problem.[71 He stated that each institution should clearly
establish its unique missions and measure itself by these
values rather than the traditional research reputation. To
accomplish this, Boyer asserted that higher education
must establish and adopt a new way of defining and
rewarding scholarship. Boyer proposed that the term
scholarship must take on a broader meaning than just
original research in order to characterize the full scope of
duties an academician is expected to accomplish in today's
higher-education institutions. He further characterized the
scholarship expected among a faculty as encompassing
four distinct functions: 1) the scholarship of discovery
(i.e., original research), 2) the scholarship of application,
3) the scholarship of integration, and 4) the scholarship of
teaching. Glassick and colleagues"] have since facilitated
acceptance of this concept by establishing criteria by
which scholarship can be measured. These criteria have
helped distinguish the difference between achievement of
excellence and scholarship. and they are enabling institutions to place equal value on all four types of scholarship.'" Although all four types of scholarship are
recognized by most institutions, most institutions require
faculty to excel in only one or two of these four options.
During the last 11 years, these pivotal reports have led
most institutions to reevaluate how faculty members prioritize their time and the faculty reward system. Therefore, when contemplating an academic position, an
individual should clearly understand the institution's
mission and faculty reward system. The faculty candidate
should also ascertain whether the assigned duties can be
accomplished according to the projected allocation of
time and effort and that they are consistent with the
faculty reward system. Individuals who select either a
college-based tenure- or nontenure-track position should
clearly understand that success in academia requires
achievement of not only excellence in completion of
assigned duties, but also s~holarship."~~]

Academia, Clinical Pharmacy Careers in

Evolution of clinical pharmacy academicians

Similar to the evolution of other clinical disciplines,
clinical pharmacy practice grew from the commitment
of a cadre of clinicians who contributed significant time in
practice and teaching."01 Because they had little time for
research and scholarship and often had limited skills in
these areas, early clinical pharmacy academicians were
sometimes viewed as quasi-faculty members. In the last
30 years, the discipline has overcome this stigma by
establishing peer-reviewed discipline-specific journals,
becoming accepted authors to journals of other academic
disciplines, and developing specialty residency and fellowship programs that prepare future clinical pharmacy
faculty members for academic careers.
The discipline now also has a cadre of clinical scientists who are fulfilling the typical academic scientist
role; but in order to accomplish this, these individuals
have had to focus primarily on teaching and research with
minimal activities in practice. Since the fundamental role
of the discipline is to prepare students for actual practice,
a cadre of clinical faculty whose primary duties are
practice and teaching are therefore also essential.
Because a broader definition of scholarship is now
accepted in higher education and it is realized that faculty members cannot effectively accomplish all four
missions, two faculty models are most frequently used
today. Individuals who assume the practitioner-educator
model are enabled to accomplish either the scholarship
of integration. application, and/or teaching because of
their focus on teaching and practice. Individuals who
fulfill the researcher-educator model are able to pursue
the scholarship of discovery because they have minimal
practice expectations.
Although clinical pharmacy has established itself in
academia, it is still in its infancy and there are unresolved
needs. Individuals who are planning for an academic
clinical pharmacy career or who are pursuing an academic
position should talk with their mentors and do further
reading about these needs. For example, fellowshiptraining programs are providing fellows with too little
time devoted to development of research abilities and too
much time devoted to teaching and practice."" It has
been proposed that clinical pharmacy training programs at
the Ph.D. level may better prepare clinical faculty to
compete for NIH funds and to study the pharmacotherapeutic and practice issues that need to be addressed in
today's healthcare environment."21 Other needs that
pharmacy schools are addressing include development
of promotion and tenure guidelines that are equitable and
consistent with the assigned duties or faculty model,

strategies to ensure that both faculty models are equally

respected and valued, and the relative proportions of each
faculty model that are needed at a pharmacy school in
order to achieve the institutional mission."'2~6"01

As noted above, a faculty member's roles and specific

responsibilities are largely determined by the institution's
mission and the assigned duties. Although there are
differences in the percentage of time that is assigned to
the areas of teaching, practice, scholarship/research, and
service, all college-based faculty members are expected to
demonstrate some level of scholarship." 91
Because faculty members have significant autonomy in
accomplishing university assignments, their responsibilities are not always clearly defined. Kennedy[13] has
concluded that in accepting academic freedom, academicians must also realize their academic duty to the institution. Kennedy further vows that academic duty is
accomplished by meeting a set of responsibilities. He
notes that the primary responsibility of academia is to
meet the needs of society since it nurtures our existence.
Faculty members can help accomplish this by meeting
specific responsibilities such as: 1) accomplishing all four
missions/responsibilities with excellence, 2 ) demonstrating commitment to students by mentoring and being wellprepared for classes, 3) maintaining high standards of
individual scholarship, 4) working "collegially" with
other faculty members so that all academic missions are
accomplished, and 5) completing all assignments ethically. It should be emphasized that collegiality requires
the faculty member to be a team member by actively
contributing to the departmental and school/college work
and actively participating in decision-making; collegiality
does not infer that the faculty member is just friendly to
everyone. Kennedy also notes that academicians have a
responsibility of commitment such that outside activities
(e.g., consulting) do not interfere with one's responsibilities to the university.

SITES AND SETTINGS

At the present time, there are 84 pharmacy schools in the
United States and each has clinical pharmacy faculty
members. Because the number of new pharmacy schools
continues to increase and a number of senior faculty
members are likely to retire in upcoming years, it has
been predicted that we may encounter a shortage of

Academia, Clinical Pharmacy Careers in

academic faculty
Since the current shortage of pharmacy practitioners is expected to continue in
the foreseeable future, the need for new clinical pharmacy
faculty members will likely persist.
Both public and private institutions serve as the
settings for these pharmacy schools. Therefore, an individual pursuing a faculty position should learn about the
characteristics of working in each of these settings. Other
considerations when selecting the institutional setting for
your faculty position include whether the institution has
its own medical center and whether your practice will be
located at a distant site away from the pharmacy school.
These factors will greatly impact opportunities for
researchkholarship, access to mentors, and ability to
develop collegial relationships.

Today, most academic clinical pharmacy faculty positions

require a .Pharm.D. degree although individuals with
another advanced degree may be considered at some
institutions. Completion of post-doctoral training programs such as specialized residencies and fellowships are
also required. Because specialized residencies focus on
development of practice skills and teaching, they can
appropriately prepare an individual for a tenure-track
practitioner-educator or a nontenure-track faculty position. Individuals who desire a researcher-educator faculty
position should complete a fellowship that emphasizes
development of research skills. Postgraduate coursework
such as biostatistics and research design would also facilitate success in a researcher-educator position and a
fellowship should provide opportunity to complete such
coursework. Many specialized residency and fellowship
training programs require completion of a general practice
pharmacy residency as a prerequisite. The requirement for
specialty faculty to become board certified is increasing
and individuals planning to enter academic clinical
pharmacy are encouraged to obtain this credential.[l6I
Some individuals may elect to gain several years of
experience as a practitioner before pursuing either postdoctoral training or a faculty position. Although this is not
required, the experience can certainly be beneficial.

AR

for promotion to the level of associate professor after a

period of 5-7 years.[51At most institutions, this requires
demonstration of scholarship/research and excellence in
accomplishing assigned duties. Most faculty members are
able to achieve the rank of full professor approximately
5-10 years after promotion to the associate professor
level. Promotion to this rank usually requires development of an established scholarshiph-esearch theme and
recognition by peers at a national level.[51The American
Association of Colleges of Pharmacy (AACP) surveys
pharmacy schools on an annual basis about the salaries of
each academic rank and publishes the results. Individuals
interested in an academic career should review these data
to gain insight into the financial aspects of the academic
pharmacy career ladder and growth. These data are
published annually and may be obtained by contacting
either an AACP faculty member or the senior vice
president at AACP.
Once either the associate professor or full professor
rank is achieved, the academician may also opt for an
academic administration career.[51 An administrative
position requires an additional set of knowledge and
skills that emphasize leadership and management. These
attributes may be gained by pursuing postgraduate degrees and, attending workshops and/or fellowships in
higher education. Most individuals begin this track by
serving as a department chair or assistant/associate dean.
Success in one of these positions can enable the individual
to become a dean. After several years of experience in any
of these positions, an individual may also pursue administrative positions in higher education that are outside of
pharmacy schools.

Although the need for clinical pharmacy faculty members will likely continue, the transformation that is occurring in higher education will make the expectations
of faculty in the future different than what they have
been in the past. Individuals contemplating an academic
pharmacy career must have a clear understanding about
the current issues and needs in order to make informed
career decisions.

AN

Most entry-level faculty positions involve appointments

at the level of assistant professor. The successful junior
faculty member usually achieves the criteria established

1. Carter, B.L. Chair report of the section of teachers of

pharmacy practice task force on scholarship definition and
evaluation. Am. J. Pharm. Educ. 1994, 58 ( 2 ) , 220-227.
2. Carter, B.L. Chair report of the AACP section of teachers

Academia, Clinical Pharmacy Careers in

3.

4.

5.

of pharmacy practice task force on faculty models. Am. J.

Pharm. Educ. 1992. 56 ( 2 ) , 195 201.
De George, R.T. Academic F r e ~ d u mand Tenure: Ethical
Issues; Iiowman KL Littlefield Publishers, Inc.: Lanham,
Massachusetts, 1997; 1-28.
MeGhan, W.F. Tenure and academic freedom: Vital ingredients for advancing practice, science, and socicty. Am.
J. Pharm. Educ. 1996, 60 (l), 94-97.
Heiberger, M.M.; Vick, J.M. Thr Academic Joh Search
Handbook, 2nd Ed.; llniversity of Pennsylvania Press:
Philadelphia, Pcnnsylvania, 1996; 161 165.
Bradberry, J.C. Some thoughts on promotion and tenure.
Am. J. Pharm. Educ. 1990, 54 ( 3 ) , 321-322.
Boyer, E.L. Scholar.ship Reconsidered. Priorities of the
Profeswriate; Princeton University Press: Princeton, New
Iersey, 1990; 1-27.
Glassick, C.E.; Huber, M.T.; Maeroff. G I . Scholarship
Assessed: Evolution o i the PI-~Jessoriute;
Jossey-Bass: San
Francisco, California, 1995; 1-25,
Hutchings, P.; Shulman, L.S. The scholarship of teaching:
-

6.
7.

8.

9.

New elaborations, new developments. Change 1999, 11

15, SeptemberjQctober.
10. Amerson, A.B. The evolution of scholarship in pharmacy
practice: Examining our direction. Am. J. Pharm. Educ.
1992, 56 (4), 421 -424.
1 I . Rhoney, D.H.; Brooks, V.G.; Patterson, J.H.; Piper, J.A.
Pharmacy fellowship programs in the United States:
preceptors. Am. J. Pharm.
12. Cohen, J.L. The need to nurture the clinical pharmaceutical
sciences. Am. J. Pharm. Educ. 1998, 62 (4), 471.
13. Kennedy, D. Academic Duty; Harvard University Press:
Cambridge, Massachusetts. 1997; 1-58.
14. Penna, R.P. Academic pharmacys own workforce crisis.
Am. J. Phann. Educ. 1999, 63 (4), 453 454.
IS. Broedel-Zaugg, K.; Henderson, M.L. Factors utilized by
pharmacy faculty in selecting their first academic position.
Am. J. Pharm. Educ. 1999, 61 (4), 384-387.
16. Wells, B.G. Board certification and clinical faculty. Am. J.
Pharm. Educ. 1999, 63 (2), 251.

PROFESSIONAL ORGANIZATIONS

Academy of Managed Care Pharmacy, Alexandria, Virginia, U.S.A.

I
The Academy of Managed Carc Pharmacy (AMCP)" was
founded in 1989 as a professional society for pharmacists
practicing in managed care settings and for their associates who subscribe to the principles underlying managed care pharmacy. It has grown steadily and substantially since its founding and is today's voice for managed
care pharmacy.

An nine-member Board of Directors, eight of whom

are elected by thc active membership, governs the
Academy of Managed Care Pharmacy; the ninth
mcmbcr is the employed Executive Director. Thirtcen
committees aid the Board in its governance, with
jurisdiction over various segments of the organization's activitics.
Committccs are comprised of member volunteers who
develop policy recommendations for the Board. All policy-making authority is vcstcd in the Board of Directors. Professional staff handles the implemcntation of
those policies.
Thc Academy is comprised of over 4800 individual
members nationally who are part of more than 600
healthcare organizations that provide comprehensive
coverage and scrviccs to the 170 million Americans
served by managed care organizations. Its active members are those pharmacists who have responsibility and

'' The AMCP is located at 100 N. Pitt Street, Alexandria, Virginia 22314:
phone: (703) 683-8416; fax: (703) 683-84 17; www.AMCP.org.

accountability for thc dccign and implementation of

managed care pharmacy benefits, and those individuals
who a\pire to that status.

The AMCP is a professional association of pharmacists

and associatcs who serve patients and the public through
the promotion of wellness and rational drug therapy by
the application of managed care principles.
The mission of AMCP is to serve as an organization
through which the membership pursues its common
goals: to provide leadership and support for its members; to represent its members beforc private and public agencies and healthcare professional organizations;
and to advance pharmacy practice in managed healthcare systems.

By 2005, the AMCP will be:

Recognized as the primary national professional
association for pharmacists and associates who practice in managed healthcare systems.
The principal source of knowledge regarding pharmaccutical care in managed healthcare systems.
An association whose members value and promote
application and advancement of pharmaceutical care
principles in managed care pharmacy.
* An effcctive voice for the principles and practices of
managed care pharmacy.
* An effective and credible public policy advocate.
(1

(1

Encyclopedia of Clinical Pharmaq

001: 10.1081E-ECP 120006282
Copyright 8 2003 by Marcel Dckker, h e . All rights reserved.

Academy of Managed Care Pharmacy

Effective at maintaining a dynamic organizational

structure that allows the association to meet its goals
through the responsible management of human, financial, technological, and other resources.

0
0
0

Serve AMCPs core constituency.

Establish a model defining the role of pharmacy within
managed care.
Define thc value of managed care pharmacy.
Be public policy advocates.
Develop a professional policy digest.

Encourage the professional development of members;

develop and improve the governance and leadership of
the organization.
Define AMCPs relationship with the pharmaceutical
industry.
Define AMCPs customers and audiences.
Identify AMCPs leadership on quality issues.

In the spring of each year, the AMCP hold< it\ Annual

Meeting. In the fall of each year, an Educational Conference 15 held.

Ainericm Council on Pharmaceutic;il Education,

Chicago, Illinois, [J.S.A.

I
The American Council on Pharmaceutical Education
(ACPE) is the national agency for accreditation of professional degree programs in pharmacy and for approval of
providers of continuing pharinace~itical education. The
ACPE was established in 1932 for accreditation of
preservicc education. In 1975, its scope of activity was
broadened to include continuing pharmaceutical education. The ACPE is an autonomous and independent agency
whose Board of Directors (the decision and policy-making
body) includes pharmacy educators, pharmacy practitioners, state board of pharmacy mcmbcrs/executives,
and public representation. A public interest panel having
at least two meinhers also provides public perspectives in
the policy and decision-making processes of accreditation.

Accreditation is the public recognition accorded a

professional program in pharmacy that is judged by
ACPE to meet established standards through initial and
subsequent periodic evaluations. The values of accrcditation are several and thc ACPE accrcditation process
scrves several constitucncics concurrently including the
general public, students and prospective students, liccnsing bodies, colleges and schools of pharmacy and their
parent institutions; and the profession. Graduates of
accredited professional programs in pharmacy should be
educationally prepared lor practice and should satisfy
educational requirements for licensure. Howevcr, dccisions concerning eligibility for licensurc reside with the
respective licensing bodies in accordance with their state
statutes and administrative rules and regulations.

Accreditation standards reflect professional and educational qualities identified by ACPE as essential to
quality professional programs of Colleges and Schools of
Pharmacy and serve as the basis for program evaluation.
8

Standards are set by the ACPE in accordance with a proccdure that provides adequate time and opportunity for all
parties significantly affected by the accreditation process
to comment on such standards prior to their adoption.
Advance notice is given whenever revision of standards is
proposed by ACPE. The initial standards were published
in 1937 and revisions have been effected, on the average,
every scvcn years in keeping with changes in pharmaceutical education and practice. (The standards and guidclines
in use prior to those presented herein were adopted in July
1984 and bccamc effective in January 1985.) These
standards and guidelines arc presented in the ACPE
Accreditation Manual, 9th Edition, September, 2000.
LL

New accreditation standards and guidelines were adopted

June 14, 1997. This occurred following a nearly SO-year
consensus building process, often fraught with controversy. The revision process leading to Accreditation
Stundmds and Guidelines j o r the Professional Program
in Phui-inucy Leading to the Doctor r?fPharmucyDegree
was initiated i n September 1989 and conducted in accord
with the Procedure and Schedule ,[or the Revision cf
Accreditation Standards and Guidelines, issued January
7, 1990. This Procedure and Schedule involved a stepwise, decadc-long process. The early years werc devoted
to study and formulation of proposed revisions and the
latcr years provided for two comment periods, each
affording open hearings and opportunities to submit
written comments. Final consideration of the last iteration
of proposed revisions, I-roposed Revision, January 15,
1996, was given during the June 1997 meeting of the
ACPE. The Accwditution Standards and Guidelines j o r
the Projessional Program in Phurmacy Leading l o the
Doctor o j Phurmucy Degree, as adopted June 14, 1997,
will be contained in the next cdition or the ACIE
Accreditation Manual. Copies of the new standards and
guidelines may be obtained by writing the ACPE olfice
(31 1 West Superior Street, Chicago, Illinois 60610,
U.S.A.), and may be found on the ACPE web site
(www .acpe-accredi t.org).
Encyclopedia qf Clinical Pharttiucy
DOI: 10.108IIE-ECP 120006267
Copyright 0 2003 by Marccl Dckkcr, Inc. All rights reservcd.

ACPE Standards 2000

Standards 2000 reflects broad input from the

profession, and sets forth expectations for quality in
Doctor of Pharmacy programs offered by colleges and
schools of pharmacy. It is expected that colleges and
schools of pharmacy maintain a fundamental commitment
to the preparation of students for the general practice of
pharmacy with provision of the professional competencies
necessary to the delivery of pharmaceutical care. For
these purposes, pharmaceutical care is defined as the
responsible provision of drug therapy for the purpose of
achieving definite outcomes that improve a patients
quality of life. These outcomes are: 1) cure of a disease;
2 ) elimination or reduction of a patients symptomatology; 3) arresting or slowing of a disease process; or 4)
preventing a disease or symptomatology.
Pharmaceutical care involves the process through
which a pharmacist cooperates with a patient and other
professionals in designing, implementing, and monitoring
a therapeutic plan that will produce specific therapeutic
outcomes for the patient. This in turn involves three major
functions: 1) identifying potential and actual drug-related
problems; 2 ) resolving actual drug-related problems; and
3) preventing drug-related problems.
Pharmaceutical care is a necessary element of healthcare, and should be integrated with other elements. Pharmaceutical care is, however, provided for the direct benefit
of the patient, and the pharmacist is responsible directly to
the patient for the quality of that care. The fundamental
relationship in pharmaceutical care is a mutually beneficial exchange in which the patient grants authority to the
provider, and the provider gives competence and commitment (accepts responsibility) to the patient. The fundamental goals, processes, and relationships of pharmaceutical care exist regardless of practice setting.
Standards 2000 sets forth 18 professional competencies that should be achieved through the college or
school of pharmacys curriculum. additionally, Standards 2000:

9.

10.

11

12.
1. Emphasizes pharmaceutical care, as considered
in the professional literature and as presented in
the Position Paper of the AACP Commission to
Implement Change in Pharmaceutical Education,
as a part of the mission statement of a college or
school of pharmacy, and as an organizing principle for curricular development.
2 . Reflects new competencies and outcome expectations for the preparation of a generalist practitioner, which are requisite to the rendering of
pharmaceutical care in a variety of practice
settings.
3 . Encourages the development of non-traditional
curricular pathways and innovative program
delivery modes (e.g., external degrees) to address

13.

14.

15.

the needs of baccalaureate-degreed practitioners

already in practice.
Encourages increased practitioner involvement in
pharmaceutical education as volunteer faculty and
in the affairs of colleges and schools of pharmacy.
Places emphasis upon the importance of developing good problem-solving, decision-making,
critical-thinking, and communication skills.
Does not distinguish between externships and
clerkships; rather, it is expected that experiential
education will be incorporated as a curricular
continuum throughout the professional program,
as both introductory and advanced practice
experiences, and that experiences will begin
earlier in the educational process.
Increases expectations regarding quality control
in the pharmacy practice experience component
of the curriculum (introductory and advanced
practice experiences).
Encourages innovation in the development and
innovation of new tactics for teaching and
learning, with particular emphasis upon increasing student involvement as active learners.
Encourages the development and implementation
of new and innovative methods for student
evaluation and assessment which measure learning at a variety of levels beyond the memorization and reiteration of facts.
Incorporates expectations that the leadership of
colleges and schools of pharmacy will undergo
formal evaluations in a regular and systematic
manner.
Expects that curricular management and editing
processes will strive to assure that the addition
of material will be counterpoised with the elimination of outdated and/or unnecessary material, so as to avoid unnecessary and undesirable
overlap.
Incorporates Total Quality Management (TQM)
principles throughout the standards and guidelines.
Expects particular emphasis to be placed upon
the professionalization (professional development) of students.
Recognizes the broad range of responsibilities of
pharmacy faculty, including teaching, research
and scholarly activities, professional practice,
service, and administration.
Expects that colleges and schools will develop
and utilize admission criteria, policies, and
procedures that consider not only academic
qualifications but also other factors which may
impact upon success in the professional program
(e.g., communication skills, etc.).

PHARMACY PRACTICE ISSUES

ori
University of Georgia College of Pharmacy, Athens, Georgia, U.S.A.

Regie Regionale de la Sante et des Services Sociaux Monteregie,

Quebec, Canada

Nonadherence to medication regimens remains a major

problem in health care. The National Council on Patient
Information and Education (NCPIE) has termed noncompliance Americas other drug problem. Pharmacists
are in an ideal position to assess and treat adherencerelated problems that can adversely affect patients health
outcomes. Strategies to monitor and improve adherence
are key components of pharmaceutical care plans, especially for patients with chronic diseases, such as hypertension, diabetes, and atherosclerotic heart disease. Nonadherence is a behavioral disorder that can be assessed
and managed through a carefully devised pharmaceutical
care plan.

Medication nonadherence is most simply defined as the

number of doses not taken or taken incorrectly that
jeopardizes the patients therapeutic outcome.[21NCPIE]
has noted that nonadherence can take a variety of forms,
including not having a prescription filled, taking an incorrect dose, taking a medication at the wrong time, forgetting to take doses, or stopping therapy too soon. In this
article, we use the term adherence instead of compliance, because the former connotes an interactive, collaborative relationship between pharmacist and patient.
Compliance originates from a practitioner-centered paradigm and is more control oriented. It relies on patient
obedience and sometimes stigmatizes the patient as en-

Copyright 1 2000 by the American Pharmaceutical Association.

Originally published in the .lournal of the American Pharmaceutical
Association; adapted with permission.

PO

gaging in deviant behavior if another course of action is

chosen.,41 A patient-centered approach is one in which
the pharmacist engages patients to become more active in
the continuum of decision making about their treatment
and the consequent health outcomes.
Although medication nonadherence is the primary
focus of this article, it is only one form of nonadherence.
Poorer health outcomes may also result when a patient
does not adhere to recommended lifestyle changes, such
as exercise or smoking cessation, or to prescribed nonpharmacologic interventions, such as physical therapy or
dietary plans. Pharmacists who counsel patients with
chronic diseases, such as asthma, hypertension, or diabetes, need to assess and promote adherence to these nonpharmacologic treatments as well.
Medication nonadherence is a major public health
problem that has been called an invisible epidemic.53h1
Nonadherence to pharmacotherapy has been reported to
range from 13% to 93%, with an average rate of 40%.L7
The problem encompasses all ages and ethnic groups. It
has been estimated that 43% of the general population,
55% of the elderly, and 54% of children and teenagers are
nonadherent. A host of individual characteristics also
influence adherence, such as the patients religion, health
beliefs, social support system, and ethnicity.
Rates of nonadherence vary with different disease
states. For example, the nonadherence rate for hypertension is reported to be 4056, while that for arthritis has been
found to range between 55% and 70%.r9Nonadherence
rates are especially high among patients with chronic diseases. These patients, who typically require long-term,
if not lifelong, medications to control symptoms and prevent complications, often must make significant behavioral changes to adhere with pharmacotherapy. Such
changes can be difficult to integrate into everyday life.
Nonadherence to pharmacotherapy has been shown to
decrease productivity and increase disease morbidity,
physician office visits, admissions to nursing homes, and
Eizcyclopedia of Clinical Pharmucy
DOI: 10.10XUE-ECP 120006252
Copyright G 2003 by Marcel Uekker, Inc. All rights reserved.

Adherence to Pharmaceutical Care

11

tions. An alternative model that can be useful for understanding and treating nonadherence is to view the problem as a disorder-a behavioral disorder.[31 Although
not a true physiological disease, nonadherence shares
many of the same characteristics as a medical disorder.
For example:

Comprehension

Beliefs, values, attitudes

Skills and willingness to perform

Fig. 1 Patient-centered adherence paradigm. In the patientcentered adherence paradigm, the pharmacist integrates information about a patient's medication use from three perspectives:
the patient's knowledge of the medication (comprehension); the
patient's beliefs and attitudes toward his or her illness and its
treatment (beliefs, values, and attitudes); and the patient's
ability and motivation to follow the regimen (skills and willingness to perform).

death."39.' For example, an estimated 125,000 deaths

per year have been attributed to nonadherence to treatment for cardiovascular disease." Many studies have
documented poorer health outcomes due to nonadherence,
especially in patients with chronic diseases such as hypertension, diabetes, and epilepsy.[5,6, 2,1 31
Finally, nonadherence places a huge burden on the
United States' economy. Its direct and indirect costs have
been estimated to be $100 billion per year in this country
alone."21 Pharmacies also lose revenue because patients
often fail to refill prescription medications, especially for
chronic disease^."^] According to The Task Force for
Compliance,"] only 25% of prescriptions for chronic
conditions are refilled after 1 year.
For pharmacists, the message is clear: To improve
adherence to pharmacotherapy, and hence to improve
health outcomes, we must assess each patient individually, then provide targeted interventions that are responsive to his or her unique risk factors and needs (see
Fig. 1). Research, such as the American Pharmaceutical Association Foundation's Project ImPACT: Hyperlipidemia,"51 has clearly documented the value of
pharmacist-led patient care in fostering better adherence
and outcomes.

''

Numerous risk factors f o r nonadherence have been

identifed. Clearly, nonadherence is a multifactorial
problem, and a host of contributing social, economic,
medical and behavioral factors have been iden[5,&,9,17-191 A
s shown in Table 1, some risk
tified.
factors for nonadherence relate to the disease (e.g., a
chronic or asymptomatic illness), others relate to the
patient (forgetfulness, sensory impairment, and economic problems), and still others relate to the drug
regimen (concerns about cost, real or perceived adverse effects, or dosing schedule).
Nonadherence can be assessed and monitored. A
variety of direct and indirect methods are available to
assess the presence and severity of nonadherence. As
pharmacotherapy specialists, pharmacists may be the
best suited of health providers to evaluate adherence
problems on an ongoing basis.
Effective interventions are available to treat nonadherence. Many cases of nonadherence can be treated
with carefully selected interventions. However, other
cases may not be resolvable, despite the best efforts of
health care providers.[51
Nonadherence frequently leads to increased morbidity and mortality. Just as untreated medical disorders
often progress to serious complications, nonadherence
has a well-documented adverse impact on health
[17,20,211
outcomes.
Nonadherence tends to have a variable course. Nonadherence is not a stable condition, but tends to progress or change over time in a given patient.[71 Just as
most chronic medical conditions require periodic reevaluation and therapeutic adjustments, patients with
adherence problems should also be reassessed on a
regular basis.
Table 1 Major risk factors for nonadherence

Nonadherence has been studied widely by behavioral

scientists whose models, such as the Health Belief Model and the Theory of Reasoned Action, attempt to explain and predict nonadherence.[I6]However, despite the
numerous articles that have been published on this topic,
nonadherence remains a problem of epidemic propor-

Asymptomatic conditions
Chronic conditions
Cognitive impairments, especially forgetfulness
Complex regimens
Multiple daily doses
Patient fears and concerns related to medication effects
Poor communication between patients and practitioners
Psychiatric illness

12

Adherence to Pharmaceutical Care

RENCE
Before effective strategies can be devised to improve
adherence, pharmacists need to evaluate how well a
patient is adhering to pharmacotherapy and identify risk
factors that may predispose the individual to nonadherence. Both direct and indirect methods are available to
assess adherence.

irect Methods
Direct and objective methods of assessing adherence
include blood-level monitoring and urine assay for the
measurement of drug metabolites or marker compounds.
Collecting blood or urine samples can be expensive and
inconvenient for patients and, moreover, only a limited
number of drugs can be monitored in this way. The
bioavailability and completeness of absorption of various drugs, as well as the rate of metabolism and excretion, are factors that make it difficult to correlate
drug levels in blood or urine with adherence. The ability of direct methods to identify nonadherence also depends on the accuracy of the test and the degree to which
the patient was nonadherent before the urine or blood
sample was taken.

Indirect Methods
Indirect methods of assessing adherence include patient
interviews, pill counts, refill records, and measurement of
health outcomes. In one study, the use of patient interviews identified 80% of nonadherent patients, as verified
by pill counts.[221The interview method is inexpensive
and allows the pharmacist to show concern for the patient
and provide immediate feedback. A drawback of this
method is that it can overestimate adherence, and its accuracy depends on the patients cognitive abilities and the
honesty of their replies, as well as the interviewers correct interpretation of responses. Pill counts provide an
objective measure of the quantity of drug taken over a
given time period. However, this method is time consuming and assumes that medication not in the container
was consumed. The refill record provides an objective
measure of quantities obtained at given intervals, but
assumes that the patient obtained the medication only
from the recorded source.
Pharmacists can generally obtain reliable information
on medication-taking behaviors from the patient or a
family member or caregiver. The interview should be
systematic and include specific questions on forgetfulness, the patients understanding of medication instruc-

tions, and the conditions for which therapy has been

prescribed. The patients health beliefs and the degree
of support available from friends and family should also
be asse~sed.~
Interviewing patients to detect nonadherence is most
effective when indirect probes are used. For instance, the
probe Most people have trouble remembering to take
their medications. Do you have any trouble remembering
to take yours? will solicit more reliable information than
asking: Are you taking your medications as prescribed? Table 2 gives examples of specific probes that
the pharmacist can use to assess whether a patient has
been or is likely to be adherent.

Table 2 Probes pharmacists can use to assess adherence

Assessing the patients medication knowledge or medicationtaking behavior

What is the reason you are taking this drug?
How do you take this medication?
Are you taking the medication with food or fluid?
Where did you receive information about this medication?
Are you taking nonprescription drugs while on this medication?
Do you use any memory aids to help you remember to take
your medication?
Do you depend on anyone to help you remember to take your
medication or to assist you in taking it?
Assessing attitudes, values, and beliefs regarding medicationtaking behaviors
What results do you expect to receive from this medication?
What are the chief problems that you feel your illness has
caused you?
Do you have any concerns about your illness and its
treatment?
Are you satisfied with your current treatment plan?
How well do you usually follow a treatment plan?
What is the main concern you have about your medication?
Do you feel comfortable asking your physician or pharmacist
questions about your medications?
Assessing whether the patient has the proper skills and is
motivated or willing to follow through on the therapy plan
Have you encountered any problems with your medication- or
pill-taking procedure?
Are you confident that you can follow your treatment plan?
What might prevent you from following the recommended
treatment plan?
How likely is it that you will ask your physician or pharmacist
about your medications?
Can you explain how you remind yourself to take your
medication on schedule?
Do you normally write down questions to ask your physician
or pharmacist before an appointment?

13

Adherence to Pharmaceutical Care

Pharmacy computerized prescription records provide

perhaps the most practical and least intrusive method
for assessing adherence. This method allows the pharmacist to review and monitor prescription records to
determine whether the patient is refilling medications in
a timely manner. Computer algorithms can be incorporated into the pharmacy computer software system as a
tool for monitoring adherence and measuring the timeliness of prescription refills.'231This method also has the
potential to flag potential adherence problems that may
develop over the course of several refills. One disadvantage of this method is that it does not assess actual

Table 3 Factors that affect medication adherence

Factors that promote adherence
Disease-related factors
Perceived or actual severity of illness
Perceived susceptibility to the disease or developing complications
Treatment-related factors
Perceived benefits of therapy
Written and verbal instructions
Convenience of treatment
Medication provides symptomatic relief
Patient-related factors
Good communication and satisfactory relationship with
physician
Participation in devising the treatment plan
Confidence in the physician, the diagnosis, and the treatment
Support of family members and friends
Knowledge about the illness
Factors that reduce adherence
Disease-related factors
Chronic disease
Lack of symptoms
Treatment-related factors
Treatment requires significant behavioral changes
Actual or perceived unpleasant side effects
Regimen complexity and duration
Medication takes time to take effect
Patient-related factors
Sensory or cognitive impairments
Physical disability or lack of mobility
Lack of social support
Educational deficiencies (literacy problem or poor English
fluency)
Failure to recognize the need for medication
Health is a low priority
Conflicting health beliefs
Economic problems
Negative expectations or attitudes toward treatment
From Refs. [3,56-581.

medication-taking behaviors (e.g., this method would

not detect a patient who was swallowing a sublingual
tablet or improperly inhaling an asthma medication from
a metered-dose inhaler).
Factors that have a negative or positive influence on
medication adherence are shown in Table 3. This table
may be used both to identify factors that contribute to
nonadherence and to develop interventions to address
adherence problems.

DESIGNING PATI~NT-FOCUSE~
INTERVENTIONS FOR NON
Strategies to improve adherence should target the specific risk factors and causes identified during the patient
assessment. Adherence aids may be used alone or in
combination, but should be tailored to the individual
patient. For example, a forgetful patient may benefit
from a special package or container that provides a
visual reminder that a medication was taken (e.g., blister packaging or a computer-aided compliance package). Forgetful patients also can be advised to take
dosages in conjunction with other routine daily activities, such as at mealtimes or before tooth brushing.
Refill reminders or automatic delivery to the home can
also be valuable for the forgetful patient, as can simplification of the dosage schedule, such as changing to
a once-daily prescription.
Once the initial adherence plan is implemented, follow-up is important to gauge how well the plan is working
and whether changes are needed. Most studies have reported that almost all adherence strategies, regardless of
their initial acceptability, will decline in responsiveness
over time.'71 Therefore. the pharmaceutical care plan must
include periodic reinforcement strategies for long-term
success. The plan should also be reevaluated from time to
time to assess its effectiveness and determine how well it
meets patient expectations.
Identifying and measuring the outcomes of a pharmaceutical care adherence plan is also important. Objective measures of improved health status and/or reduced
health care expenditures document success in a well-designed pharmaceutical care plan. Examples of measurable
outcomes include a reduction in inappropriate use of the
health care system (e.g., fewer emergency department visits for asthma exacerbations) or improved control of the
patient's disease (e.g., HbA1, levels below 7% in a patient
with type 2 diabetes).
The results of Project ImPACT: Hyperlipidemia
demonstrate that a pharmacist-oriented program to improve adherence can dramatically improve health out-

Adherence to Pharmaceutical Care

14

comes.51 Project ImPACT, which stands for Improve

Persistence And Compliance with Therapy, was conducted in 26 community-based ambulatory care pharmacies in 12 states. The programs objective was to demonstrate that pharmacists, working collaboratively with
patients and physicians, could improve patients adherence to prescribed therapy for dyslipidemia and help them
achieve their National Cholesterol Education Program
(NCEP) goals.
Remarkably, over an average of 24.6 months, 93.6% of
Project ImPACT patients adhered to their prescribed
therapy and 90.1% persisted with therapy through the
studys end.[51 Among patients with existing coronary
artery disease, 48% attained their NCEP goal, far better
than in any previously published national study of patients
with hyperlipidemia. The authors stated that collaboration
between pharmacists, patients, and physicians, using pharmacy-based testing for blood lipids and pharmacist-led
counseling, could reduce the risk of heart disease and
stroke by one-third.

Although pharmaceutical care plans should be individualized, some adherence-promoting strategies tend to be
helpful in the majority of patients. Whenever possible, the
pharmacist should strive to
8

Promote self-efficacy. Encourage patients to assume

an active role in their own treatment plans. In general, the more confident people feel about their ability to manage a problem, the more likely they will
be to take positive action to solve that problem. Involving patients in decisions about their care is important for promoting self-efficacy. For example, a
study by Nessman and colleagues[241 showed that
patients with hypertension who were highly involved
in decisions about their therapy and trained to take their
own blood pressure had significantly better health
outcomes than patients who did not have these characteristics. The authors attributed the improved outcomes to the patients ability to make choices about
health care decisions and follow through on a monitoring plan.
Empower patients to become informed medication
consumers. A pharmaceutical care plan to enhance
adherence should first focus on educating the patient and family members or caregivers about the patients disease and medications. Pharmacists should
provide both written and oral information to address

such basic questions as: What is the disease? Which

treatments have been prescribed or recommended and
why? What is the patients role in managing the
disease? Which adverse effects may occur? Perhaps
surprisingly, the amount of factual information that a
patient has about his or her medication is not highly
correlated with adherent beha~ior.~]
Instead, the patients functional knowledge-that is, information that
is directly useful and meaningful to the patient-and
clear instructions for medication use are more significant.[251Opportunities to impart functional knowledge begin with the physician andlor nurse at the time
of the initial prescription, and should be reinforced by
the pharmacist when the prescription is filled or
refilled.
Avoid fear tactics. Scaring patients or giving them dire
warnings about the consequences of less-than-perfect
adherence can backfire and may actually worsen adherence.[261A more constructive approach is to help
the patient focus on ways to integrate medication taking into their daily routine. ~ 2 7 1
Help the patient to develop a list of short- and longterm goals. These goals should be realistic, achievable,
and individualized. The pharmacist can also make
contractual agreements with the patient to encourage development of constructive behaviors, such as
getting more exercise or beginning a smoking cessation program.
Plan for regular follow-up. The pharmacist should
plan to interact with the patient at regular, usually
brief intervals to reinforce the adherence plan. For
example, brief appointments can be scheduled when
patients visit the pharmacy for prescription refills.
The plan should be adapted to the patients lifestyle
and be reevaluated from time to time to adjust for life
changes, such as aging or a change in work or school
schedules. If possible, the time for counseling on adherence should be separated from the dispensing and
pick-up functions.
Implement a reward system. Giving prescription coupons or specific product discounts for successfully
reaching a goal in the treatment plan can help to
increase adherence, particularly in patients with low
motivation.

pecial Populations
Although the problem of nonadherence affects all ethnic
and age groups, some populations are more vulnerable
than others. Pharmacists should be especially alert for
adherence problems in high-risk populations, such as the

15

Adherence to Pharmaceutical Care

Table 4 Resources for improving patient adherence

Organizations
National Council on Patient Information and Education
(NCPIE)
4915 Saint Elmo Ave., Suite 505
Bethesda, MD 20814-6053
301-656-8653
www.talkaboutrx.org
Among other resources. NCPIE publishes Prescription
Medicines and You: A Consumer Guide, a large print
brochure available in English, Spanish, and Asian languages.
United States Pharmacopeia (USP)
12601 Twinbrook Parkway
Rockville, MD 20852
800-822-8772
www.usp.org
USPs many resources include MedCoach patient information leaflets, which are available at two reading levels and
may contain pictograms.
Resources for Special Populations
For low literacy patients
Responding to the Challenge of Health Literacy. The Pfizer
Journal. Spring 1998;2(1):1-37.
Available from: Impact Communications, Inc.
330 Madison Avenue, 21st Floor
New York, NY 10017
212-490-2300
For older adults
The Eldercare Patient Education Series
The Peter Lamy Center for Drug Therapy and Aging
University of Maryland School of Pharmacy
506 West Fayette Street, Suite 101
Baltimore, MD 21201
http://gerontology .umaryland.edu/docs/lamy
.html
e-mail: [email protected]
For children
The Pediatric Medication Text
(Patient information for 200 commonly prescribed pediatric
medications; available in English and Spanish)
American College of Clinical Pharmacy
3101 Broadway. Suite 380
Kansas City. MO 641 11
816-531-2177. ext. 20
www.accp,com/ped-medtxt.htm1
For ethnic minorities
Closing-the-Gap.com
This online magazine provides resources for health care
providers and consumers to promote minority health through
culturally relevant care.

elderly, children, low-literacy individuals, and some

ethnic minorities. Table 4 provides resources that can
aid pharmacists in improving adherence in these highrisk groups.

The elderly
Although older Americans (ages 65 and older) account for
less than 15% of the population, they consume about 33%
of all prescription medications and 40% of nonprescription drugs.[*] Poor adherence in the elderly often leads to
additional physician or emergency department visits,
hospitalization, and uncontrolled chronic diseases. One
study estimated that about 17% of elderly hospitalizations
are due to adverse medication reactions-nearly six times
the rate in the nonelderly population.[291
A variety of often-interacting risk factors increase the
risk of nonadherence among the elderly. Risk factors in
this population include
0

Polypharmacy. Elderly patients are more likely to take

multiple medications, including both prescription and
nonprescription products. Whenever possible, the
medication regimen should be simplified. The pharmacist also should consider the extent to which the
mode of drug delivery (e.g., pill, patch, or inhaler) may
influence adherence.
Physical impairments. Age-related physical disabilities, such as difficulty getting out of bed or a chair,
may limit an elderly persons ability to take medication consistently. Traditional packaging of medication also may be an impediment to some elderly
patients; for example, individuals with arthritis in their
hands may have trouble opening containers. For these
patients, consider options such as use of unit-of-use
packaging, unit-dose packing, or blister packaging.
The pharmacy environment should also be friendly
to senior citizens. For example, elderly patients with
hearing problems may need a quiet place to receive
patient counseling so as not to be distracted by ambient noise. Written materials should be available in
large type (14-point font size) for people with vision
problems.~301
Cognitive limitations. Memory loss and other cognitive problems may interfere with adherence by causing
patients to fail to understand or remember medication
DO1
instructions.
For these patients. pharmacists may
need to provide medication instructions several times
and in different formats, such as both verbal and
written information.
Limited access to or affordability of health care services, Many elderly patients are on fixed incomes. A
study conducted by the consumer advocacy group
Families USA reported that over the past 5 years, the
prices for the 50 prescription drugs most commonly
used by the elderly have increased faster than inflation.13 Elderly patients who are unable to afford

16

Adherence to Pharmaceutical Care

certain medications may be eligible for various forms

of state or federal aid, or special discounts from pharmaceutical manufacturers.
Pharmacists should also consider how an elderly
patients relationship with other health care providers
might influence adherence. For example, research shows
that the elderly tend to favor partnership-type relationships with their physicians and that satisfying patientprovider relationships contribute to better adherence.[321
However, with the growing number of managed care and
group practices, these relationships are often more difficult to develop. A good pharmaceutical care plan can
help elderly patients relate more effectively with primary
care providers by helping these patients understand the
nature of their diseases and how to better communicate
their needs to physicians.
The role of a patients caregivers in helping or hindering medication adherence also should be considered. A
motivated and well-informed caregiver can be essential
for optimizing adherence in an elderly patient. However,
caregivers can sometimes hinder adherence efforts. For
example, a caregiver who is having trouble coping with
an elderly patients behavioral or cognitive problems may
demand medications to sedate the patient. Pharmacists
who serve communities with a large elderly population
may want to hold special classes to teach caregivers about
medication management, addressing topics such as medication administration and how to monitor and report adverse effects.

Low-literacy patients
Patients who read poorly or not at all are at high risk
for poor adherence. According to the U.S. Department
of Education National Adult Literacy Survey,[331 40
million people in the United States are functionally illiterate and another 55 million are only marginally
literate. Patients with low literacy skills are less likely
to be adherent to their medication regimens and appointments, or to present for care early in the course of
their disease.[341
Inadequate health literacy skills have been shown to
adversely affect the management of a number of chronic
diseases, including diabetes and hypertension. For example, in a study of hospitalized patients, 49% of patients
with hypertension and 44% of those with diabetes were
found to have inadequate health literacy.[351In that study,
as many as 50% of patients did not understand how
many times a prescription should be refilled. After examining a standard appointment slip, up to 33% could not
describe when a follow-up appointment was scheduled,

and as many as 50% could not determine whether they

were eligible for financial assistance based on their income and number of children.[351
People with low health literacy may not understand
the health risks associated with errors in medication
management. Shame or embarrassment about their low
literacy may deter them from seeking help with medication instructions. Pharmacists can assess health literacy using nonobtrusive screening tests such as the Test
of Functional Health Literacy in Adults (TOFHLA),
which is available in English and Spanish versions.[361
This test includes items that assess the patients ability to
understand labeled prescription vials, blood glucose test
results, clinic appointment slips, and financial information forms.
On a more practical level, pharmacists also should
strive to provide patient educational materials that are
written at a low literacy level. The National Work Group
on Literacy and Health[371 recommends that materials
should be at the fifth-grade level or lower, yet most
patient education materials are written at the eleventhgrade level. Patient education materials should be short,
simple, and contain culturally sensitive graphics. Easy-toread written materials should be combined with verbal
instructions, which ideally should be repeated on several
different occasions to reinforce patient understanding.
Involving family members in the patient education process also can promote adherence.
Many literacy organizations recommend that pictograms and warning stickers be affixed to prescription
bottles and nonprescription product packages. A detailed
list of pictograms and a summary of research on their
usefulness for low-literacy populations are available
from the United States Pharmacopeia (USP) at www.
usp.org. In addition, multimedia computer-based educational programs are available that permit patients to
choose to see or hear information about their particular
medical condition.

Ethnic minorities
An extensive literature documents persistent differences in health outcomes between ethnic minorities and
white Americans. These disparities include differences
in health care access and utilization as well as health
status and outcomes. W o l i n ~ k y [ ~showed
~]
that differences in access and use of health services by various
ethnic groups stems in part from their varying cultural
traditions. Pharmacists can assist in closing this gap in
health outcomes by providing culturally sensitive patient
care. Information about patients cultural health care
beliefs and practices is essential for devising interven-

Adherence to Pharmaceutical Care

tions to improve adherence. To provide care that is responsive to cultural differences, pharmacists should strive
to develop the following three skills:371
Communicate information that is both accurate and
understandable to the patient. This shll involves the
use of interviewing techniques to assess the patients
literacy level, possible language barriers. and cultural
health beliefs. Insufficient English language skills are
a major barrier for some minority patients. Depending
on the pharmacys location and clientele, Spanish or
other foreign language versions of patient ehucation
materials may be necessary.
* Openly discuss racial or ethnic differences. A patients cultural health beliefs can contribute greatly to
adherence problems. For example, a patient may believe that the body needs periodic rests from medications during long-term therapy or that daily
medication use is dangerous because it can lead to
addiction. Getting to know the patient and their beliefs
requires time, but it fosters the development of a
trusting relationship. The pharmacist should try to ascertain the answers to the following questions: Does
the patient understand their diagnosis and the purpose
of the medication? How do the patients cultural
health beliefs influence their understanding of the illness? Is the patient using any other therapies, such as
complementary or alternative medicine, in addition to
prescription medications? Does the patient have any
religious beliefs that might affect the decision to adhere to the treatment plan?
* Use community and other resources on behalf of the
patient.371 A disproportionate number of patients in
some minority groups have limited incomes, which
can be a major barrier to obtaining medications. Patients with low or fixed incomes who do not qualify
for medicare and medicaid often have difficulty in
securing the appropriate supply of their medications.
A number of programs are in place to provide free
medication and counseling for low-income patients.
For example, the volunteer-managed Crisis Control
Pharmacy in North Carolina provides free medications that range from one-time-only prescriptions to
long-term maintenance therapy. Each patient is evaluated on the basis of their financial need. Another
example is the Medical Access Program (MAP), offered by the University of Georgia College of Pharmacy through the Carlos and Marguerite Mason Trust.
The mission of MAP, which serves an ethnically
diverse low-income population, is to increase medication access for organ transplant patients who live in
Georgia.i391

11

Children
With a growing number of prescription drugs being developed and marketed specifically for children and adolescents, nonadherence is becoming a significant problem in the pediatric population. According to NCPIE,[401
only one-third of children take medications as prescribed
or recommended by physicians. In a study by Bush et
al.[431one-third of the children in grades 3 to 7 reported
they had used one or more prescription or nonprescription medications in a 48-hour period. Another study of
children 9 to 16 years old, who were attending summer
camp, revealed that almost one-half had brought and
used a supply of medications, many without the knowledge of camp personnel.[421Adherence plans for children
often require innovative approaches to teach them how
to use their medications appropriately and to encourage
active participation in caring for their own health.
The literature offers a number of recommendations that
can help pharmacists to improve adherence in children.
Some suggestions are as follows:
a

Teach children early in life to assume some responsibilitj f o r taking their medications. According to the
Childrens Health Belief model developed by Bush
and I a n ~ t t i , ~
children
~]
formulate health beliefs and
expectations about medication use early in their development. The authors recommend that children, especially those with chronic illnesses, assume some
responsibility at an early age for taking their medications. Young children who are taught to use medications wisely may be less likely in later life to engage in
high-risk behaviors such as illicit drug use or
medication abuse.441Such children may also be more
discerning about the quality of information they receive about medications from their peers, and from
television and other media.
Educate the parents, too-particularly the mother. In
young children, most risk factors for nonadherence
reside in the parent. In most cultures, the mother
plays an extremely important role in supervising the
care of a sick child. For example, even though young
children may have an aversion to the bad taste of
the drug, they usually take their medications because
their mothers tell them it is necessary to feel better.
Research shows that children internalize parental beliefs, which greatly influence their attitudes and behaviors toward health problems as they mature into
adults.411
Adapt the educational program to the childs cognitive
level and stage of development. Education should be
based on the childs maturity and ability to grasp

Adherence to Pharmaceutical Care

18

essential concepts about the disease and medication.

According to one study, physicians and pharmacists
rarely talked with children about medications, yet most
children wanted to know about their medicines and
would ask their physicians or pharmacist if they
coUld.[411Children as young as 5 years of age knew
there was a difference between medications for children versus those for adults.[411They could grasp the
concept that medications for adults would be too
powerful for a little body. Older children perceived
the risk for adverse reactions better than the younger
children did. Older children also could understand the
cost-benefit of getting well despite the need to
take a bad-tasting medicine. These children wanted to
have more personal control and independence in making decisions about their medication use. Finally, although most children did not know how medications
worked, they were very much interested in this topic.
Bush and her colleagues[451developed a cognitive
developmental model for educating children about
medications that is based on Piagets cognitive development theory. This model recommends teaching
children about the therapeutic purpose of their medications and that medications can be both helpful and
harmful (i.e., good drugs versus bad drugs, or poisons).
For younger children, learning activities should be interactive and fun. For older children, education should
correct earlier misconceptions and naive theories about
medications that may have been learned earlier in their
development. Older children may enjoy learning about
medications through the use of computer games, videos, and reading materials.
Relate the need f o r medications to a childs past experiences with the illness. For example, if child is being recalcitrant about receiving immunization against
influenza, the pharmacist might use a probe such as,
Do you remember the yucky flu you had last year?
Would you like to avoid that this year? This approach can help the child remember previous bouts of
the flu as an awful-feeling illness. The child then can
understand the need to prevent the illness by receiving
the flu vaccination.
Specific guidelines for developing interventions to address adherence problems in children can be found in
the USPs Ten Guiding Principles for Teaching Clzildren and Adolescents about Medicines. These principles
were developed on recommendations from more than
100 health care professionals, educators. and consumer
representatives who attended the USPs fall 1996 open
conference, Children and Medicines: Information Isnt
Just for Grownups. The proceedings of this conference and

the recommendations can be accessed at www.usp.org/

information/programs/children/principles.
htm.

Each chronic disease presents its own constellation of

adherence problems. A brief overview of adherence strategies for two major public health problems-hypertension and type 2 diabetes-illustrates disease-specific risk
factors for nonadherence and shows how pharmaceutical
care services can enhance adherence.

Hypertension
Because hypertension is usually a silent disease, most
patients do not experience symptoms that remind them of
the need for taking medications. Without symptoms, it is
more difficult to establish a link in the patients mind
between taking the medication and controlling hypertension and its complications. Because patients often do not
feel or perceive the benefits of their treatment, the first
step in enhancing adherence is to educate them about
hypertension and its serious complications, such as coronary heart disease, stroke, and renal failure.
Pharmacists who want to maximize adherence to
pharmaceutical care programs for hypertension should
first read the Sixth Report of the Joint National Committee
on Prevention, Detection, Evaluation, and Treatment of
High Blood Pressure.[461This report encourages a greater
interdisciplinary role for pharmacists in monitoring medication use and providing patient information. Adherence
to therapy is a key consideration for reaching the 2010
national goals for blood pressure control.[461Only onehalf of patients with hypertension still take their medications after the first year of treatment, and one-third of
them do not take enough medications to keep their blood
pressure under control.[71
The primary goals of a pharmaceutical care plan for
hypertension are to improve patient adherence, decrease
the risk of developing complications, and reduce the cost
of unnecessary emergency department visits and hospital
stays. Simplified dosage regimens, such as once- or twicedaily dosing, have been shown to enhance adherence in
hypertensive patients. In one study, adherence rates were
73% and 70% for once-or twice-daily regimens, respectively, versus 52% and 42% for three- and four-times-aday regimens.[471 Improving adherence is particularly
important with the newer regimens, because drug concentrations may be subtherapeutic when dosing delays or
omissions
Common adverse effects of antihy-

Adherence to Pharmaceutical Care

pertensive therapy, such as fatigue, impotence, and lightheadedness, also can adversely affect adherence.
Patients may need advice on how to incorporate
medications and other antihypertensive treatments, such
as exercise recommendations, into their daily activities
and lifestyles. One useful strategy is to help patients
establish cues that will serve as reminders to take medication, such as after breakfast, after brushing teeth, or
just before bed.
As with other chronic diseases, education of caregivers
and family members is crucial. In one study, 70% of
patients wanted their family members to know more about
hypertension. The patients reported that negative attitudes, insufficient family support, and lack of confidence
in the management of their blood pressure were contributing factors to their long-term adherence problems.[491
Whenever possible, a family member or caregiver should
be included in educational sessions to help the patient
follow instructions and stay on track over time.
Social or group support can also help to boost the
patients confidence and sense of self-efficacy. Group
social support may be available from a patient advocacy
organization, such as a local chapter of the American
Heart Association.
To promote adherence to long-term therapeutic interventions, the pharmacist and patient may agree on a
contract that includes a series of mutually agreed-upon
and realistic health goals. Once a target goal has been
achieved, the pharmacist can provide the patient with a
reward, such as a discount on a prescription, a coupon for
store merchandise, or a colorful certificate announcing
successful goal attainment. Rewards should be carefully
staged so they serve as motivators and are not so ostentatious as to overpower the effect of personal satisfaction
from a job well done. The pharmacist and patient also can
collaboratively develop periodic reports about the patients progress for the primary care physician.
The pharmaceutical care plan should include outcome
measures to gauge the success of adherence strategies for
hypertensive patients. Outcomes might include refill
patterns for patients taking long-term medications and
periodic measurement of blood pressure control over
time. Quality-of-life measurements and patient satisfaction surveys are also appropriate outcome measures. The
former are useful to monitor the progress or potential
complications in patients receiving lifelong therapy for
asymptomatic diseases such as hypertension.[501

Type 2 Diabetes
Type 2 diabetes is reaching epidemic proportions in the
United States, largely because of rising rates of obesity,

19

physical inactivity, and an aging population. Studies have

conclusively demonstrated that the complications of
type 2 diabetes can be greatly reduced or delayed by
intensive medical management.[511However, it is estimated that only 7% of patients with diabetes adhere
fully to all aspects of their regimen.[521Adherence rates
for insulin-injection regimens range from 20% to SO%,
adherence to dietary recommendations is about 6556,
and adherence to exercise regimens varies from 19% to
30%. Glucose-monitoring adherence rates range from
57% to 70%.521
Hsiao and Salmon[533 reported that patients beliefs
about the benefits of diabetes therapy are important in
determining whether they obtain and use medication. In
general, the more severe the patients disease and the
greater the perceived susceptibility to complications, the
more likely the patient is to be adherent. Patients must be
convinced of the seriousness of their disease and empowered to monitor themselves for diabetic complications. Patients with diabetes who were at high risk for
nonadherence included older people, men, and those with
low socioeconomic status.531
Pharmacist-led programs can be extremely effective in
improving adherence to diabetes care, as two independent
pharmacies in Richmond, VA, recently demonstrated in a
year-long program. During the first 6 months of the program, enrolled patients experienced an average decrease
in their morning glucose values from 178.6 mg/dL to
159.3 m g / ~ l L . [ ~Remarkably,
~I
over the 12-month study
period, participants had an average adherence rate of 90%
for their use of diabetes medications.
To help the pharmacists identify medication problems,
a prescription record review was performed 6 months
after the start of the study. In addition, a computerized
diabetes checklist was generated and given to each
patient to complete at every prescription refill. Along with
other information, the checklist asked about any medication-related problems the patient had experienced since
the last refill and assessed the patients pattern of blood
glucose self-monitoring. The program also included a
systematic review of appropriate medication dosages, potential drug or disease interactions, and potential adverse
drug reactions.
At each refill visit, the pharmacist reviewed the
plan with the patient and provided reminders about
the need for other preventive care. such as yearly eye
exams and proper foot care. When appropriate, the physician was contacted, with the patients consent, regarding specific treatment recommendations. In summary,
this diabetes monitoring program showed the value of
combining multiple interventions to improve adherence
and outcomes.

Adherence to Pharmaceutical Care

20

herence Services
Considering that pharmacies lose nearly $8 billion yearly
from unrefilled prescriptions, improving adherence is well
worth the effort.[41 Huffman and Jackson[551estimated
that by increasing the number of refills by only lo%, a
pharmacy could increase its annual sales by $55,000 and
net profit by more than $8000. Adherence screening,
monitoring, and implementation of interventions also take
time, and pharmacists may seek compensation for the
hours they spend in those activities. Third-party payers
have begun to realize the value of adherence management, and some payers may be willing to pay for adherence-related services. Patients also may be willing to pay
out of pocket for these services. To increase the likelihood
of reimbursement, pharmacists should be sure to document their adherence-related activities, such as patient
assessment, education, and counseling.
Pharmacists also can benefit from building professional
relationships with a core network of physicians who can
refer patients to the pharmacy for adherence-related services. Reimbursement for cognitive services or disease
state management programs is often tied to provider referrals. Providers usually make referrals to other specialists based on trust and their expertise and professional
competence. A physician is more likely to refer a patient to
a pharmacy when they have confidence in the content of
the services and the competence of the pharmacist administering the therapeutic plan. Accountability (i.e., having the name of an individual, rather than an organization,
responsible for the services rendered) is also important.

Space Considerations
Assessment of and counseling on adherence is best done
face to face. The use of a special counseling area is recommended, especially when counseling requires more
time or privacy. Although extensive renovation of the
pharmacy is usually not needed, the environment should
be conductive to open communication, with enough privacy for patients to feel free to discuss personal matters.
Environmental barriers, such as a desk or prescription
counter, may pose a physical barrier to communication
and should be avoided, if possible. Adequate privacy is
also important, especially when patients are discussing
sensitive medical matters and others could overhear.
Ideally, the counseling area should be free of distractions,
such as ringing telephones or other conversations. The
counseling area should have enough space for the phar-

macist to demonstrate the use of medications or devices,

to write instructions, and to store written materials for
distribution. A chair should also be available for patients
to sit during counseling sessions.

Making Time for Adherence Services

It can be challenging for pharmacists to find ways to
incorporate adherence screening and monitoring into their
current organizational structures. Use of pharmacy
technicians to perform routine dispensing duties can free
time for the pharmacist to provide cognitive services, such
as assessment and counseling. Innovative scheduling
methods may also free up time for patient education and
counseling. For example, there may be a brief overlap of
pharmacist coverage during the times immediately before
and after work shifts. Another strategy is to schedule
patient appointments during times when the pharmacy
workload is lighter.

SUMMARY
Adherence to pharmacotherapy is essential to optimal
therapeutic outcomes. The pivotal role of the pharmacist
in optimizing adherence encompasses many actions: assessing the adherence problem, identifying predisposing
factors, providing comprehensive counseling, and recommending specific adherence strategies targeted to the patients needs. Patients who have chronic conditions, physical or cognitive impairments, or cultural backgrounds
outside the mainstream may have special needs that
should be addressed in the adherence plan. Pharmaceutical care plans also should take into account the patients
age, stage of life, and literacy level. Although a wide
range of adherence aids and strategies are available, the
key to success is to tailor the intervention to the individual
patient and, when necessary, to combine interventions to
optimize adherence.

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PHARMACY PRACTICE ISSUES

Duquesne University, Pittsburgh, Pennsylvania, U.S.A

Negatively affects prognosis or results in temporary or

permanent harm, disability, o r death (5)
Adverse drug reactions (ADRs) are types of adverse drug
events (ADEs) (1). ADEs include ADRs, medication
errors, and other drug-related problems. ADEs are the
negative conscqucnces of drug misadventures. Henri
Manasse defined drug misadventure as the iatrogenic
hazard that is an inherent risk when drug therapy is
indicated. This chapter will focus on ADRs.

The World Health Organizations (WHO) and Karch and

Lasagnas definitions of an ADR are quite similar. An
ADR is any response to a drug that is noxious and
unintended, and occurs at doses used for prophylaxis,
diagnosis, or therapy, excluding failure to accomplish the
intended purpose (2). The Food and Drug Administration
(FDA) focuses on ADRs that have unexpected rcactions
and/or those of more signilkant morbidity. These ADRs
would include those where the patient outcome is death,
life-threatening, hospitalization, disability, congenital
anomaly, or required intcrvention to prevent permanent
impairment or damage (3). The Joint Commission on
Accreditation of Hcalthcare Organizations (JCAHO) is
conccrned with the reporting of significant ADRs. Thosc
that result in morbidity, require additional treatment,
require an incrcased lcngth 01 stay, temporarily or
pcrmanently cause disability, or cause death must be
reported to the FDA (4). The American Society of HealthSystem Pharmacists (ASHP) defines significant ADRs as
any unexpected, unintended, undesired, or excessive
response to a drug that includes thc following:
Requires discontinuing the drug
Requires changing the drug therapy
Requires modifying the dose
Necessitates admission to thc hospital
Prolongs stay in a health care facility
Necessitates supportive treatment
Significantly complicatcs diagnosis
Encycioprdici oj Cliiiical Plrai-mac.y
DOI: 10.I081/E-ECP 120006420
Copyright G 2003 by Marcel Dekker. Inc. All rights rcscrved

The ASHP definition does not include reactions due to

drug withdrawal, drug abuse, poisoning, or drug
complications.
Other terms that may be included as ADRs are side
effects, drug intolerance, idiosyncratic reactions, toxic
reactions, allergic reactions, or hypersensitivity reactions
(6). Side <feels are rcactions that are unintended and
unwanted but arc known pharmacologic effects of the drug
and occur with predictable lrequency. Drug intolprunce is a
mild reaction to a drug that results in little or no change in
patient management. Idiosyncratic reaction is an uncxpected response that occurs with usual dose of a drug. Toxic
reuction is a predictable response that results from greater
than recommended drug dosages or drug concentration in
thc body. Allergic or hypu.sensitivilj reaction is an unusual
sensitivity to a drug of an immunologic nature.

Four classification systems are uscd to describe

ADRs (1, 7). ADRs can be classified according to
thepharmacologic effect of the drug-Type A, B, C, and
D reactions. Type A reactions are exaggcrated but normal
pharmacologic actions o f a drug. They arc predictable and
dose dependent. Type B reactions are not predictable
given the known pharmacologic action of a drug and are
not dose related. Many of these Type B reactions are
hypersensitivity or immune-based. These reactions can bc
further subdivided into type 1 (IgE-mediated rcaction),
II(1gG or IgM-mcdiated cytotoxic reaction), 111 (IgGmediated immune complex reactions), and TV (ccllmediated immune reaction). Typc C reactions are those
due to long-term use of a drug. Typc D reactions are
delayed drug effects, such as due to carcinogenicity or
teratogenicity.
ADRs can also be classified according to the dose
relationship, i.e., dose-related and non-dose-related reactions. Another classification system is based on thc causal
relationship between the reaction and thc drug. One of the
23

24

Adverse Drug Reactions

most widely used causality classifications is based on

Naranjo s descriptions. These categories include definite
(drug is likely the true cause), probable (drug is the
apparent cause), possible (drug appears to be associated),
and remote (drug is not likely to be the cause). The fourth
classification system is based on degree of injury or
severity of reaction. There are mild reactions (temporary
discomfort and tolerable), moderate (significant discomfort), and severe (potentially life threatening or causing
permanent disability or death).

The frequency of ADRs in the general population is

unknown. However, the reported rates of new occurrences
for ADRs are noted for selected patient populations. A
meta-analysis of 39 prospective studies reported an overall
incidence of serious ADRs in hospitalized patients of 6.7%
and of fatal ADRs of 0.32% (8). The fatality rate makes
ADRs the fourth to sixth leading cause of death in the
United States. Another meta-analysis of 36 studies
indicated that approximately 5 % of hospital admissions
are due to ADRs (9). The costs of ADRs are estimated to
be $1.56-$4 billion in direct hospital costs per year in the
United States (10).

ISP

RS

Two major factors predispose to adverse drug reactions:

the drug itself and patient factors. Factors related to the
drug include its dose, dosage form and delivery system,
and interactions between drugs. Patient-related factors
include age, disease states, genetics, gender, nutrition,
multidrug therapy use, and use of herbal therapies.

Drug-Related Factors

Dose
ADRs may be the result of ingestion of increased amounts
of a drug. Dosing issues are especially likely with narrow
therapeutic index drugs. Examples of these types of drugs
include digoxin, anticoagulants, anticonvulsants, antiarrhythmics, antineoplastic agents, bronchodilators, sedatives, and hypnotics (1 1).

Dosage form and delivery system

Many of the ADRs related to the dosage form and
delivery system are the result of local irritation or

hypersensitivity reactions (12). Local irritation to the

gastrointestinal (GI) tract can occur with oral dosages.
For example, toxicity resulting in mouth ulcerations is
associated with antineoplastic drugs. In addition, the use
of certain formulations, such as sustained release
preparations, can increase esophageal injury if esophageal transit is delayed. For example, a controlled
release wax matrix of potassium chloride has been
associated with significant esophageal erosions. Factors
identified to predispose to esophageal injury include
large film-coated tablets, capsules, large sustainedrelease preparations, rapidly dissolving formulations,
and ingestion of solid oral dosage forms before bed rest
with very little water intake (12).
Localized tissue irritation can be seen from the
intramuscular (IM) route. This is especially an issue
when the formulation pH differs from the pH of the
surrounding tissue or when precipitation of poorly soluble
drugs occurs (12). Incorrect administration of I M
injections is probably the most important factor that
causes local adverse effects. Local skin irritation can also
be seen with transdermal delivery systems due to the
alcohols, nonionic surfactants, and adhesives.
Hypersensitivity reactions can occur due to the
presence of contaminants or excipients in pharmaceutical
dosage forms (e.g., outbreaks of eosinophilia-myalgia
syndrome associated with oral tryptophan contaminants in
various drugs) (12). Another example is the anaphylactoid
reactions to the surfactant Cremaophor EL, which is used
in paclitaxel (Taxol).
Direct toxicity effects related to use of preservatives
also has been documented. For example, severe
metabolic acidosis and death in infants was attributed
to the presence of benzyl alcohol. a preservative used in
bacterostatic normal saline that was used to flush
catheters (12).
The use of specific intravenous (IV) delivery devices
also can cause ADRs. For instance, use of plastic infusion
sets for IV administration of nitroglycerin has resulted in
subtherapeutic effects due to diffusion of the drug into the
plastic tubes (12).
Formulation effects, such as bioavailability differences,
can cause ADRs when patients are switched to generic
products. For example, significant adverse effects
have occurred with anticonvulsants and thyroid preparations (12).

Interactions between drugs

It has been estimated that 6.9% of ADRs are due to drugdrug interactions (6). The most likely reason for an adverse
drug interaction is the pharmacokinetic changes that result
in altered metabolism or excretion of drugs, or the

Adverse Drug Reactions

25

pharmacodynamic changes that result in synergistic or

additive effects of drugs.

Patient-Related Factors
Age, disease states, genetics, gender, nutrition, multidrug
therapy use, and herbal therapies use are patient-related
factors that influence the likelihood of adverse drug
reactions.
Age-geriatrics
Age-related alterations in pharmacokinetics and pharmacodynamics may affect the response of elderly patients to
certain medications, and may increase the susceptibility for
ADRs among elderly patients (13- 15) (Table 1). The risk
of ADRs among elderly patients is probably not due to age
alone. ADRs may be related more to the degree of frailty
and medical conditions of the patient (15). On average,
older persons have five or more coexisting diseases that
may increase the risk of adverse events. Polypharmacy
seems to be more of a common problem among the elderly.
The average elderly patient takes 4.5 chronic medications
and fills 13 prescriptions yearly (15). Elderly patients
appear to have a decline in homeostatic mechanisms. The
imbalance of homeostatic mechanisms and the decline in
function reserves may put a patient at greater risk for ADEs
due to decreased tolerance of medications and the ability to
handle stressful situations (16).
Age-pediat rics
The two factors responsible for increasing risks of ADRs
in children are pharmacokinetic changes and dose
delivery issues. Age-related differences in pharmacokinetics in children are documented (17). However, the data
on both efficacy and safety are often limited or not
studied at all in this population. Thus, it is unclear

Table 1

whether an increased risk for ADRs exists in this group.

However, there is a potential risk for increased ADRs if
appropriate considerations are not taken into account in
view of pharmacokinetic changes (18).
It is important to note that only one-fourth of the drugs
approved by the FDA have indications specific for use in a
pediatric population (17). Medications used in adults are
often given to children without FDA safety and efficacy
data. Compatibility and stability issues with dosage forms
intended for adults that have been altered (e.g., dilution or
reformulation) can increase risks for ADRs.
Information on pediatric age-related difference in
neonates, children, and adolescents may aid in prevention
of pediatric ADRs (18) (Table 2). Further studies of drug
use in pediatrics are needed in order to prevent ADRs.
Concurrent diseases
Diseases such as hepatic or renal diseases can influence the
incidence of ADRs by altering the pharmacokinetics of
drugs, such as absorption, distribution, metabolism, or
excretion (6).
Hepatic disease
Patients with liver disease have an increased susceptibility
to certain drugs due to decreased hepatic clearance for
drugs metabolized by the liver or due to enhanced
sensitivity (6). For example, impaired hepatic metabolism
can precipitate central nervous system (CNS) toxicity in
patients on theophylline, phenytoin, or lidocaine; or ergot
poisoning on ergotamine (19).
Increased sensitivity to drugs is also encountered in
liver disease( 19). The use of anticoagulants increases the
risk of bleeding due to the reduced absorption of vitamin K
or decreased production of vitamin K-dependent clotting
factors. There is an enhanced risk for respiratory
depression and hepatic encephalopathy due to morphine

Geriatric age-related changes in pharmacokinetics

Pharmacokinetic phase

Gastrointestinal absorption
Distribution

Oxidation drugs
Renal excretion
= Decreased;

1 = Increased.

Pharmacokinetic parameters

Unchanged passive diffusion and no change in bioavailability for most drugs

1 Active transport and T bioavailability for some drugs
1 First-pass effect and 1bioavailability
1 Volume of distribution and T concentration of water soluble drugs
T Volume of distribution and half-life for fat soluble drugs
t or 1 free fraction of highly plasma protein-bound drugs
1 Clearance and 1' half-life for some Phase I
1. Clearance and half-life of drugs with high extraction ratio
1 Clearance and 1 half-life of renally eliminated drugs

26

Table 2 Pediatric age-related risk factors and causes of ADRs

Neonates:

Placental transfer of drug before birth

Differing drug action
Altered pharmacokinetics
Increased percutaneous absorption
Decreased renal/hepatic function
Decreased plasma protein binding
Use of multiple drugs
Limited information on drug action in critically ill and premature
neonates
Children:

Paradoxical effect of medications (excitability rather than

sedation from antihistamines)
Excipients of liquid dosage forms
Sugar as sweeteners
Propylene glycol as solvent
Large volume intravenous solutions
Treatment of viral infections with antibiotics
Disruption of neurologic and somatic development
Adolescents:

Autonomy seeking
Use and misuse of devices (e.g., tampons)
Use and misuse of prescription and nonprescription medications
Poor compliance with instructions
Use of multiple medications
Recreational use of alcohol and illicit drugs
Effects of changing hormone levels on drugs
(From Ref. 7.)

or barbiturates in patients with severe liver disease.

Vigorous use of diuretics can precipitate hepatic coma due
to potassium loss in liver disease. There is an increased
risk of hypoglycemia with sulphonylurea antidiabetic
drugs due to decreased glycogenesis in liver disease.
Liver disease can also cause hypoalbuminemia due to
decreased liver synthesis of albumin. For drugs that are
extensively bound to albumin, such as phenytoin, an
enhanced risk of drug toxicity could occur because of the
increase in free drug concentration.
There are no useful methods to quantify the degree of
liver disease that can assist in dosage adjustment. A
practical approach involves checking patients for elevated
prothrombin time, rising bilirubin levels, and/or falling
albumin levels. In such instances, drugs that have an
altered response in liver disease or cause hepatotoxicity
need to be avoided.
Renal disease
Impaired renal function increases the incidence of ADRs
for drugs that depend on the kidney for their elimination.

Adverse Drug Reactions

Unlike liver disease, use of pharmacokinetic dosing

principles can minimize the risk for adverse effects.
Mechanisms responsible for enhanced ADRs in renal
disease include delayed drug excretion, decreased protein
binding due to hypoalbuminemia, and increased drug
sensitivity (6). Delayed renal excretion is responsible for
enhanced toxicity with drugs such as aminoglycosides,
digoxin, vancomycin, chlorpropamide, H2-antagonists,
allopurinol, lithium, insulin, and methotrexate (20). For
some drugs, the accumulation of a toxic metabolite during
renal failure is responsible for ADRs. This is the case with
meperidine, where a toxic metabolite, normeperidine,
accumulates in renal failure (20).
Patients with accumulation of uremic toxins have
increased sensitivity to certain drugs. There may be an
enhanced response to CNS depressants (such as barbiturates and benzodiazepines), hemorrhagic effects from
aspirin or warfarin, and other bleeding effects from
antibiotics that inhibit platelet aggregation, such as
carbenicillin, ticarcillin, and piperacillin.
Other diseases
On theoretical grounds, other diseases associated with
hypoalbuminemia could predispose patients to adverse
reactions and to altered responses to drugs that are highly
protein bound (21) (Table 3).
The presence of other diseases can influence the risk for
ADRs. Many of these adverse effects are related to an
extension of the pharmacologic effects of the drug in the
presence of certain pathophysiology. Numerous examples
are given in Table 4 (6).
Patients who have had a previous reaction to drugs are
also more likely to experience an ADR (22).Patients with
history of allergic diseases also have an increased risk due
to a genetically related ability to form immunoglobulin E.
Genetic factors
Genetic factors account for some ADRs due to either
altered pharmacokinetics or by altering tissue responsiveness. Altered metabolism of drugs occurs due to

Table 3

Conditions associated with hypoalbuminemia

Aging
Burns
Cancer
Cardiac failure
Protein-losing enteropathy
Inflammatory diseases
Injury
Immobilization

Liver disease
Nephrotic syndrome
Nutritional deficiency
Pregnancy
Renal failure
Sepsis
Stress
Surgery

Ocular
Narrow-angle glaucoma

Cerebrovascular
Rheumatic
Systemic lupus
Hy pcruriccmia
Respiratory
Asthin a
Respiratory insufficiency
Endocrine disorders
Diabetes mellitus
Hypothyroidism
Hypcrthyroidism

Epi1epsy

Hematologic
Blceding disorders-hemophilia
Neurological disorders
Myasthenia gravis

Hypertension

Bradycardia

Myocardial ischcinia

Ischemic episodes
Increased incidence of drug reactions in general
Gouty attack
Acute bronchospasms
Hypoventilation, respiratory arrest
Hyperglycemia; aggravatcs diabetic control
Enhanced response
Enhanced response
Decreased response

Drugs
Thiazide diuretics. furosemide
p-Blockers
Narcotic analgcsics
Thiazide diuretics, furosemide, corticosteroids, oral contraceptivcs
Digoxin
Oral anticoagulants
Digoxin

Glaucoma attack

Aggravate muscle weakness

Para Iy sis
Lower seimre thrcshold

Aminoglycosides
Quinidinc, quinine
Phcnothiazines
Tricyclic antidepressants
Ergotaminc

Anticholinergics

Increased risk of hemorrhage

Aspirin

Incrcascd blood pressure

Decreased blood pressurc

Aggravatc or precipitate heart failure

Enhanccd toxicity-seizures
Disturbances of cardiac ratc, rhythm, and conduction
Arrhythmias
Cardiac standstill

P-Blockers
Lidocaine, theophylline
Tricyclic antidepressants
Digoxin
P-Blockers
Quinidine
Oral contraceptivcs, vasoconstrictors
Phcnothiazines, nitrates
Tricyclic antidcprcssants

Adverse reactions
Risk of bleeding or perforation of ulcer

Drug

Aspirin, corticosteroids, nonsteroidal antiinflammatory drugs

Influence of diseases on adverse drug reactions

Gastrointestinal
Peptic ulcer
Cardiovascular
Hcart failure

Disease

Table 4

v)

E.

PR

119

Ei

(D

Adverse Drug Reactions

28

differences in hydrolysis. acetylation, and hepatic

oxidation of drugs. Altered pharmacodynamic reactions
could be either an exaggerated response or a qualitative
response. These types of reactions are unpredictable.
Examples of altered drug response due to genetic factors
are found in Table 5 (6).

Gender
A higher incidence of ADRs has been reported for women
in comparison to men (6). One reason for this observation
is that women take more drugs than men. Yet, no sexlinked differences in drug pharmacokinetics have been
documented. Other reports have not supported a higher
incidence of ADRs in women as compared to men. Thus,
sex alone is unlikely to be a major determinant of ADRs.

Nutrition
Nutritional factors are also responsible for ADRs. These
factors include the interaction of drugs and nutrients, and
altered pharmacokinetics related to nutritional status.
One study reported a very low incidence (0.4%) of
clinically significant drug-nutrient interactions in a
teaching hospital (23). Three mechanisms postulated for
drug-nutrient interactions are interference with drug
absorption, alteration of drug excretion, and affecting drug
activity. For example, the absorption of tetracycline is
reduced by chelation with iron, calcium, and magnesium.
Foods that acidify or alkalinize the urine can affect drug
excretion. Foods that contain a large amount of vitamin K
can inhibit the activity of warfarin. A listing of important
drug-nutrient interactions is found in Table 6 (23). A
review article on drug-food interactions in clinical
practice is found in Ref. 24.
Drug-nutrient interactions may be more highly
significant in renal failure patients. A review article of
drug-nutrient interactions in renal failure has been
published (25).
Nutritional status can affect drug pharmacokinetics.
Malnutrition states can cause the following: 1) the liver
and kidneys changes affect drug elimination; 2 ) GI system
changes affect drug absorption; 3) changes in the heart
affect blood flow; 4) hormone changes affect metabolic
enzymes and drug binding proteins; 5 ) plasma, tissue
proteins, and body composition changes affect protein
binding and elimination; 6) mineral and electrolyte
changes affect drug metabolism and protein binding; and
7 ) tissue changes affect uptake of drugs and drug-receptor
interactions (26).

Multidrug use
According to several epidemiological studies, multiple
drug use has a strong association in the causality of ADRs.

It has been suggested that the more medications used, the

higher the risk for ADRs (27). Consistent drug regimen
reviews by healthcare providers in order to reduce
polypharmacy may decrease the risk of ADRs.

Herbal therapies use

The use of herbal therapies increased dramatically
during the 1990s. Herbal therapy sales are estimated to
be $4 billion a year, with sales increasing at 20% per
year since the early 1990s ( 2 8 ) . Patients often
mistakenly believe that since these products are natural,
they d o not possess the potential harm as in
prescription medications. Since herbal medications are
sold and marketed without stringent FDA approval and
guidelines, limited evidence-based data on efficacy,
adverse effects, and drug interactions exist. Recently,
two review articles examined available data on ADRs
for the most common herbal medications (28, 29).
Many of these available reports fall short on
documentation of temporal relationship with the specific
ADR and the herbal drug.
For most conditions, herbal products are not a
replacement for proven prescription or nonprescription
drugs. Patients should be aware that health care
practitioners cannot guarantee the safety and consistency
of herbal products. Patients should start with the
recommended effective doses and report any unusual
side effects to their health care practitioner. Patients
should always consult with their pharmacist for possible
drug-herbal interactions. Side effects and possible drug
interactions for the ten most commonly used herbals are
listed in Table 7 .

ADVERSE DRUG REACTION

REPORTING SYSTEMS
The WHO, the FDA, the JCAHO, and the Health Care
Financing Administration (HCFA) have all addressed
and mandated the need for health care institutions to
implement an ADE detection and reporting system.
Detection systems are instrumental in postmarketing
surveillance of ADRs. The JCAHO requires all
accredited health care institutions to have an ongoing
drug surveillance program (4). The goals of ADR
detecting and reporting systems are to aid in
postmarketing surveillance of FDA approved medications and to identify ways to decrease ADR risks.
The main focus of all of these reporting systems is to
aid in promoting improvements in the medication use
process.

Phenytoin, carbamaIepine, phenobarbital

Deficiency of epoxide hydrolase

Acetaminophcn, ancsthctics, topical, benzocaine,

chloroquine, dapsone, nitrites, primayuinc,
sul fonamides
Anesthetics, gcneral, (halothanc), muscle relaxants
(succinylcholine)

Mcthemoglobin reductase deficiency

Abnormality of calcium regulation

Aspirin, BAL (dimercaprol), chloroquinc,

chloramphenicol, dapsone hydroxychloroquinc,
nalidixic acid, nitrofurantoin, primayuine, probenecid.
yuininc, yuinidinc, sulfonamides

More prone to hepatitis

Isoniazid

Rapid acetylator

Pharmacodynamic
Glucoac 6-phosphatc
dehydrogenase deficiency (G-6-PD)

More prone to sidc effccts

Phenelzine, sulfasalaLine

Malignant hyperpyrexia

Methemoglobi nemi a

Hemolytic anemia

Life threatening hypcrsensitivity syndrome

due to accumulation of toxic
intermediates

Increased incidence of SLE-like syndrome

Hydralazinc, procainamide

Prolongcd ncuromuscular blockade lcading to

apnca

Adverse drug response

Increased incidence of peripheral neuropathy;

SLE-like syndrome; and more prone to
phenytoin toxicity

Drug(s)

Isoniarid

Slow acetylator

Pharmacokinetic
Low plasma pseudocholinestcrase
Succinylcholine

Gcnetic factors and altered drug re5ponscs

Genetic mechanism

Table 5

W
w

a
;

30

Table 6

Adverse Drug Reactions

Important drug-nutrient interactions

Drug
Phenytoin

Nutrient

Interaction

Alcohol

Enhanced metabolism of phenytoin

Enteral feedings

Decreased phenytoin absorption

Tetracycline

Dairy products

Impaired drug absorption

Theophy lline

Caffeine

Potential for toxic effects

Warfarin

Foods high in vitamin K

Decreases anticoagulant response

Chlorpropamide, tolbutamide, tolazamide,

acetohexamide, metronidazole

Alcohol

Disulfiram-like reaction

Trancy Icypromide

Foods high in tyramine

Hypertensive crisis

Disulfiram

Alcohol

Nausea, blurred vision, chest pain,

dizziness, fainting

Spironolactone

Foods high in potassium

-

Hyperkalemia

(Adapted from Ref. 2 3 . )

The best methodology for screening for ADRs has not been
determined. However, several screening methods have
been proposed. In particular, the literature has highlighted
five screening methods using clinical data (30-34). The
five include screening for: 1) tracer drugs, e.g., antidotes
such as vitamin K and diphenhydramine; 2) narrow
therapeutic range drugs, e.g., follow-up of computer lab
values for warfarin and digoxin; 3) change in medications,
e.g., documentation of discontinued medications or
decreased dose; 4) diagnosed ADRs documented in the
medical record, e.g., chart review or reviewing ICD-9 CM
(International Classification of Diseases, Ninth Revision,
Clinical Modification) codes; and 5) ADR computer report
tracking systems. Although each of these ADR screening
methods has been described in detail, limited data are
available on the productivity of these screens.

Systems for Pharmacoepidemiologic Studies

Pharmacoepidemiology is used to detect ADRs (35, 36).
Several types of systems use pharmacoepidemiologic
methods. These include spontaneous reporting, studies of
therapeutic classes, and studies of specific medical
syndromes.

Spontaneous reporting
Spontaneous reporting is currently the major backbone for
the detection of ADRs (37). It occurs in one of three ways:

1. Reporting to the FDA as part of clinical trials;

2. Reporting by practitioners to medical journals; or

3. Patients self-reporting to either manufacturers or the
FDA (38).
Clinical trials in new drug development cannot detect
all the possibilities for drug safety. Limitations in Phase 111
clinical trials include a relatively small sample size, short
duration of the trial, restricted populations (e.g., geriatrics
and pediatrics), uncomplicated patients, (e.g., limited
disease states), and limited power for adverse drug
reaction detection (30). Thus, the FDA relies heavily on
spontaneous reporting of suspected ADRs (39). Spontaneous reporting is important in early market history of
the drug to determine previously unidentified drug
reactions. This has been particularly true in the last few
years because of numerous new medications that have
entered the market and now carry a black box warning. For
example, Rezulin@ and Trovan@ are associated with
hepatotoxicity and carry black box warnings.
Additional advantages of spontaneous reporting systems include the detection of extremely rare ADRs and
ability to identify at-risk subgroups. In order to enhance
the spontaneous reporting system approach, the FDA
developed the MedWatch form. This form can be faxed to
the agency (1-800-FDA-1078) or called in (1-800-FDA1088) (40). The forms also can be obtained by the
MedWatch Online internet-based website (http://www.
fda.gov/medwatch/).
Limitations of FDA spontaneous reporting include both
under-reporting and over-reporting .
An example of over-reporting occurs with recently
approved drugs. This is partly due to enhanced publicity
about these drugs.

Adverse Drug Reactions

Table 7

31

ADRs for the top ten herbal medicines

Herbal

Common use

Side effects and interactions

Echinacea

Treatment and prevention of upper

respiratory infections, common cold

Rash, pruritis, dizziness, unclear long-term

effects on the immune system.

St. Johns wort

Mild to moderate depression

Gastrointestinal upset, photo-sensitivity.

Mild serotonin syndrome with the following
medications: paroxetine, trazodone, sertraline, and
nefazodone.
May decrease digoxin levels.
May decrease cyclosporine serum concentrations.
Combined oral contraceptives-breakthrough bleeding.

Gingko biloba

Dementia

Mild gastrointestinal distress, headache, may

affect warfarin (increase INR).
Interaction with aspirin (spontaneous hyphema)

Garlic

Hypertension, hypercholesterolemia

Gastrointestinal upset, gas, reflux, nausea,

allergic reactions, and antiplatelet effects.
May effect warfarin (increase INR)

Saw palmetto

Benign prostatic hyperplasia

Uncommon

Ginseng

General health promotion, sexual function,

athletic ability, energy, fertility

High doses may cause diarrhea,

hypertension. insomnia, nervousness, may affect
warfarin (decreased INR)

Goldenseal

Upper respiratory infections. common cold

Diarrhea, hypertension, vasoconstriction

Aloe

Topical application for dermatitis, herpes.

wound healing, and psoriasis, orally
for constipation

May delay wound healing after

topical application.
Diarrhea, and hypokalemia with oral use

Siberian ginseng

Similar to ginseng

May raise digoxin levels.

May affect warfarin (increased INR)

Valerian

Insomnia, anxiety

Fatigue, tremor, headache, paradoxical insomnia

(not advised with other sedative-hypnotics)

Studies of therapeutic classes

Observational cohort or case control designs have been
used to determine ADR relationships with specific
therapeutic classes (36, 41). Medical claims data are
often used in these studies and caution should be warranted
due to lack of definite confirmation of drug exposure and
the potential for confounding variables (38). However,
these studies have been beneficial in determining risk of
ADRs with specific classes (e.g., NSAIDs and the risk of
peptic ulcer disease) (42).

Studies of specific medical

syndromes
Observational cohort or case control designs can also be
useful to study possible causality relationships of specific
medical conditions or syndromes due to drug exposure (36,
41). These types of studies have been particularly useful in
examining ADRs in a specific population, such as geriatric

or pediatric patients. These groups of patients are often

excluded in Phase I11 trials. However, a disadvantage of
these studies is that they also often use administrative data.
These data can warrant risk of problems in determining
causality due to potential confounding variables (38).

Assessing Adverse Drug

Reactions
After detection of a possible ADE, causality assessment
needs to be performed. It is important to be able to rank the
likelihood of an ADR as unlikely, possible. probable, or
definite. A major problem with determining causality is that
confounding variables can contribute to the complexity of
causality assessment (43). In order to determine causality,
several important points of data are required. These include
the nature of the adverse event, name of the putative drug,
other potential causes, and the temporal relationship

32

Adverse Drug Reactions

Table 8

ADR Naranjo causality algorithm

Yes

NO

1. Are there previous conclusive reports on this reaction?

2. Did the adverse event appear after the suspected drug was administered?
3. Did the adverse reaction improve when the drug was discontinued, or a
specific antagonist was administered?

+1
+2

-1

4. Did the adverse reaction reappear when the drug was readministered?

+2

-1

5. Are there alternative causes (other than drug) that could on their own caused
this reaction?
6. Did the reaction reappear when a placebo was given?

-1

+2

-1

+1

7. Was the drug detected in the blood (or other fluids) in concentrations known
to be toxic?

+l

8. Was the reaction more severe when the dose was increased, or less severe
when the dose was decreased?

+l

9. Did the patient have a similar reaction to the same or similar drugs in any

+l

+l

$1

0
0

Do not know

Score

0
0
0

previous exposure?

10. Was the adverse event confirmed by any objective evidence?

0
Total score

Probability category scores: Definite

9; Probable 5-8; Possible 1-4; Doubtful

between the drug and adverse event. Potential causes are

obtained by examining the medical history, physical
examination findings, and directed diagnostic tests.
Identification of causality can be performed simply by
using a health care providers clinical reasoning and judgment. The main disadvantage to this approach is a low interrater and intra-rater agreement for ADR causality (44.45).
An ADR causality algorithm addresses the issue of
inter-rater and intra-rater reliability with a series of clinical
questions. For example, the Naranjo algorithm consists of
a series of clinical questions that focus on temporal and
dose-response relationships, consistency of the ADR with
previous clinical reports or patient experiences, placebo
response, drug dechallenge and rechallenge, toxic blood
drug concentrations, alternative causes of the reaction, and
whether the event was confirmed by objective evidence
(44) (Table 8). Numerous health care institutions and the
FDA use some type of causality algorithm to minimize
disagreement among different evaluators and improve
inter-rater and intra-rate agreement.

PREVENTING A
REACTIONS
ADRs are problematic in that they cause significant
morbidity and mortality. Almost 95% of ADRs are Type A

0.

(predictable) reactions, and thus with quality improvement

measures, ADRs can be avoided and prevented (46).
Knowledge of causative factors and an increase in patient
education may help prevent ADRs. Improvements in the
documentation of allergic reactions (e.g., via computer
tracking), development of tools to enhance compliance,
and application of tools to improve prescribing and
administration of drugs are other preventative approaches
to ADRs.
In 1994, the ASHP, the American Medical Association
(AMA), and the American Nurses Association (ANA)
generated the following system of recommendations to
prevent ADRs in health care systems:

1. Health care systems should establish processes in

which prescribers enter medication orders directly into
computer systems.
2 . Health care systems should evaluate the use of
machine-readable coding (e.g., bar coding) in their
medication use processes.
3. Health care systems should develop better systems for
monitoring and reporting adverse drug events.
4. Health care systems should use unit dose medication
distribution and pharmacy-based intravenous medication admixture systems.
5 . Health care systems should assign pharmacists to work
in patient care areas in direct collaboration with
prescribers and those administering medications.

Adverse Drug Reactions

6. Health care systems should approach medication errors

as system failures and seek system solutions in
preventing them.
7. Health care systems should ensure that medication
orders are routinely reviewed by the pharmacist before
first doses and should ensure that prescribers,
pharmacists, nurses, and other workers seek resolution
whenever there is any question of safety with respect to
medication use (47).

33

11.
12.
13.
14.

SUMMARY

15.

Adverse drug reactions are of significant concern in the

pharmaceutical technology arena. Various drug and
patient factors that predispose to ADRs have been
identified. Reporting systems used to screen and assess
ADRs facilitate the understanding of risk factors and
contribute to the development of systematic improvement
in the prevention of ADRs.

16.

17.

18.
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ONeil, A.C.; Petersen, L.A.; Cook, E.F.; Bates, D.Q.;

Lee, T.H.; Bcnnan, T.A. Physician Reporting Compared
With Medical-record Review to Identify Adverse Medical
Events. Ann. Intern. Med. 1993, / 1 9 , 370-376.
Prosscr, T.R.; KamysL, P.L. Multidisciplinary Adverse
Drug Reaction Surveillance Program. Am. J. Hosp. Pharm.
1990, 47. 1334- 1339.
Porta, M.S.; Hartzema, A.G. The Contribution of
Epidcmiology to the Study oP Drugs. Drug. Intell. Clin.
Pharm. 8987, 21, 41 -47.
Strom. B.L., Ed. Pha,-nzncoe~.l?idenziologl.,2nd Ed.; John
Wiley: Chichester, 1994.
The Detection qf New Adverse Drug Rractions;
Stephens, M.D.B., Ed.; The MacMillan Press: Basingstoke,
I988.
Hanlon, J.T.; Schmader, K.; Lewis, 1. Adverse Drug
Reactions. T1ic.rupeutic.s in the B1derl.y; Delafuente, J.C.,
Stewart, R.B., Eds.; Harvey Whitney Rooks: Cincinnati,
1995; 212-227.

39.

40.

41.

42.

43.

44

45.
46.
47.

Kennedy, D.L.; McGinnis, T. Monitoring Adverse Rrug

Reactions: The FDAs New MedWatch Program. Pharmacol. Ther. 1993, 833-834, 839-842.
Kessler, D.A. Introducing MEDWatch: New Approach to
Reporting Medication and Device Adverse Effects and
Product Problems. J.A.M.A. 1993, 269: 2765-2768.
Pharmacoepidemiolo~~:
An Introduction; Hartzema, A.G.,
Porta. M.S., Tilson, H.H., Eds.; Harvey Whitney Books:
Cincinnati, 1991.
Guess, H.A.; West, R.; Strand, L.M.; Helston, D.;
Lydick, E.G.; Bergman, C.A.; Wolski, K. Fatal Upper
Gastrointestinal Hemorrhage of Perforation Among Users
and Nonusers of Nonsteroidal Anti-Inflammatory Drugs in
Saskatchewan, Canada 1983. J. Clin. Epidemiol. 1988, 41,
35-45.
Meyboom, R.H.B.; Hekster, Y.A.; Antoine, C.G.;
Gribnau, F.W.J.; Edward, 1.R. Causal or Casual? The
Role of Causality Assessment in Pharmacovigilance. Drug
Saf. 1997, 6 , 374-389.
Naranjo, C.A.; Busto, U.; Sellers, E.M.; Sandor, P.; Ruiz,
I.; Roberts, E.A.; Janecek, E.; Domecq, C.; Greenblatt,
D.J. A Method for Estimating the Probability of Adverse
Drug Reactions. Clin. Pharmacol. Ther. 1981, 30,
239-245.
Karch, F.E.; Lasagna, L. Adverse Drug Reactions: A
Critical Review. JAMA 1975. 234, 1236- 124 I.
Rawlins, M.D. Adverse Reactions to Drugs. Br. Med. J.
1981, 82,974-976.
American Society of Health System Pharmacists. TopPriority Actions for Preventing Advcrse Drug Events i n
Hospitals: Recommendations of An Expert Panel.. Am. J.
Health-Syst. Pharm. 1996, 53, 747-751.

PROFESSIONAL ORGANIZATIONS

University of North Carolina, Ch,ipel Hill, North Carolina, U.S.A.

Agency for Healthrare Research and Quality, Rockville, hlarylnnd, U.S.A.

As early as 1965, whcn Medicare and Medicaid became

law, it was recognized that research and evaluation would
be necessary to guide the progress of these programs.
Because Medicare and Medicaid were born as amendments to the Social Security Act, the Office of Research
in the Social Security Administration provided modest
support for research to address important issues. Under
the rubric health services research the effort was
expanded, first as the National Center Tor Health Services
Research (NCHSR), and later as the Agency Tor
Healthcare Policy and Research (AHCPR). The legislature that established AHCPR dcscribed its mission as:

The purpose of the Agency is to enhance the quality,

appropriateness. and cffectiveness of healthcare services,
ess to such services. through thc establishment of a
broad base of scientific research and through the promotion
of improvements in clinical practice and in the organisation, financing, and delivery of healthcare serviccs.
In 1999 the name was changed to the Agency for
Healthcare Research and Quality, removing the word
policy from the namc. Thc new name clarified the
mission of AHRQ by indicating it is to conduct and
disseminate research that may be uscd by policymakers,
but does not itself determine Federal healthcare policies
and regulations. It is a scientific research organization; it
is not a policy-setting organization. Further, adding the
word quality to the name established that AHRQ is
the lead federal agency on quality of healthcare research.
This rcsponsibility includes coordinating all federal
quality improvement efforts and health services.

The agcncy supports, conducts, and disscminates research that improves access to carc and outcomes of
Eizc)iclopcdici of Cliniccd Ilitrr-incq

DOI: lO.1081IE-ECP 120006178

Copyright C 2003 by Marcel Dekker, lnc. All rights reacrvcd

care, as well as the cost, quality, and utilization of

healthcare services. Succinctly stated, AHRQs mandate
is to sponsor research that provides better information
and enables better decisions about healthcare. In order
to accomplish this mission, the agency has three strategic g o a ~ s : ~

I . Support improvements in health outcomes.

2. Strengthen quality mcasurement and improvement.
3. ldentify strategies to improve access, foster appropriate use, and reduce unnecessary expenditures.
These goals are pursued and measured using the following definitions:
Health outcomes research examincs the end results of
the structures and processes employed in delivery of care.
An important consideration in this research is the patients
perspective. as well as the public and private-sector policymakers who are conccrncd with the impact of their investment in healthcare.
Quality measurement and improvement requires developing and testing quality measures and invcstigating the
best ways to collect, compare, and communicate these
data so they are useTul to decision makers. AHRQs research emphasizes studies of the most effective ways to
implement these measures and strategies in order to improve patient safety and healthcare quality.
Improving access, fostering appropriate use, and reducing unnecessary expenditures continues to be a challenge for the poor, the uninsured, minority groups, rural
and inner city residents, and other priority populations.
The agency supports studies of access, healthcare utilization, and expenditures to identiTy whether particular
approaches to healthcare delivery and payment alter behaviors in ways that promote access andlor economize on
healthcare resource use.
Four specific areas of research were mandatcd by
Congress in 1999 and havc been adopted by AHRQ as
35

36

Agency for Wealthcare Research and Quality

current research priorities. Research grants or contracts

awarded to investigators in the foreseeable future will
likely fall within these areas.[31

uality of Healthcare
AHRQ is to coordinate, conduct, and support research,
demonstrations, and evaluations related to the measurement and improvement of healthcare quality. AHRQ is
also to disseminate scientific findings about what works
best and facilitate public access to information on the
quality of, and consumer satisfaction with, healthcare.

Promote Safety and Reduce Medical Errors

AHRQ will develop research and build partnerships with
heath care practitioners and healthcare systems, and
establish a permanent program of Centers for Education
and Research in Therapeutics (CERTs). These initiatives
will help address concerns raised in a 1999 report by the
Institute of Medicine (IOM) that estimates as many as
98,000 patients die as a result of medical errors in
hospitals each year.'41

of ~ ~ f Q r ~ a tTechnology
iQn
Patient Care a

AHRQ will promote the use of information systems to

develop and disseminate performance measures, create
effective linkages between health information sources
to enhance healthcare delivery and coordinate evidencebased healthcare services, and promote protection of individually identifiable patient information used in health
services research and healthcare quality improvement.

ffice of Priority Populations

The needs of low-income groups, minorities, women,
children, the elderly, and individuals with special
healthcare needs will be addressed through the agency's
intramural and extramural research portfolio.

SPECIAL INITIATIVES
AHRQ has several initiatives that should be of particular
interest to the clinical pharmacy community. These include the Centers for Education and Research in Therapeutics (CERTs), the Evidence Based Practice Centers
(EPCs), National Guidelines Clearinghouse (NGC), and
a coordinated set of activities with the goal of Translating Research Into Practice (TRIP).

In 1994 Woosley raised concern about the quality and

quantity of prescription drug information available to
physicians and other practitioner^.'^] He contrasted the
billions of dollars available from commercial interests to
promote prescribing and use of (primarily new) drugs,
with the limited funds available to help practitioners
select cost-effective therapeuties. What was missing was
a balance between commercially driven information and
nonproprietary information, a vacuum that Woosley
proposed would be filled by CERTs. The conceptual
basis for CERTs was that of an academic entity capable
of striking a balance between the relative abundance of
pharmaceutical industry-generated information, and the
relative paucity of NIH- or FDA-generated information
available to practitioners.
Congress recognized the importance of the CERTs
concept and directed the formation of the CERTs in
Section 409 of the Food and Drug Modernization Act
(FDAMA) of 1997 and authorized AHRQ to establish
CERTs as a demonstration effort. Congress intended
CERTs to have a dual mission of conducting essential
research not otherwise performed by the pharmaceutical
industry, and to communicate to practitioners information
concerning the most effective, safest, and least-expensive
therapies. Each Center was to have a focus based upon a
therapeutic area of interest and a defined population,
leading to a national network with complementary resources and interests.
In October, 1999 AHRQ awarded funds to four CERTs,
and soon followed with awards for three additional
CERTs. The seven CERTs and their areas of interest are:

Duke University

Improving Prescribing for

Cardiovascular Illness
Georgetown University
Preventing Drug-Drug
Interactions in Women
Harvard University
Demonstration of Implementation
of Improved Prescribing
Practices in an Integrated
Network of HMOs
University of Alabama
Improving Drug Therapy for
Musculo-skeletal Disorders
at Birmingham
University of North
Rational Drug Therapy for the
Pediatric Population
Carolina at Chapel Hill
University of Pennsylvania Applying Pharmacoepidemiological Methods to
Improved Prescribing
Comparison of Therapeutic
Vanderbilt University
Effectiveness of Selected Drugs
in the TennCare System

Agency for Healthcare Research and Quality

The CERTs legislation has been transferred from

FDAMA to AHRQ, and is now a permanently authorized
program. The CERTs network is expected to expand,
both through addition of new Centers as well as establishment of collaborations with investigators and practitioners throughout the country. Additional information is
available at http:Nwww.certs.hhs.gov.

Evidence-Based Practice Centers (EPCs)

The philosophy of evidence-based practice is widely accepted, although operational and implementation issues
represent major barriers. One of the significant barriers
is a shortage of evidence reports on topics of critical
interest, and the lack of a national infrastructure to prepare such reports. In response to this need, AHRQ has
funded 12 Evidence-based Practice Centers to conduct
systematic, comprehensive analyses and syntheses of
the scientific literature to develop evidence reports and
technology assessments on clinical topics that are common, expensive, and present challenges to decision makers. Since December 1998, l l evidence reports have
been released on topics that include sleep apnea, traumatic brain injury, alcohol dependence, cervical cytology,
urinary tract infection, depression, dysphasia, sinusitis,
stable angina, testosterone suppression, and attention
deficit hyperactivity disorder.
Pharmacotherapy is a significant interest within the
EPCs, and AHRQ welcomes partners such as specialty
societies and health systems to submit topics for evidence
reports, participate with the EPC s in preparing reports,
and most importantly to use the findings of EPCs to
develop tools and materials that will improve the quality
of care.

National Guidelines Clearinghouse (NGC)

Developed in partnership with the American Medical
Association and the American Association of Health
Plans, the NGC is a Web-based resource for information
on evidence-based clinical practice guidelines. The NGC
began providing online access to guidelines at http://
www.guideline.gov in 1998. Since becoming fully operational, the site receives over 100,000 visits each month.
The site provides information to help healthcare professionals and health system leaders select appropriate
treatment recommendations by providing full text or an
abstract of the recommendations, by comparing and
evaluating different recommendations, and by describing
how they were developed. Because almost all guidelines
include some consideration of pharmacotherapy, and the
NGP should be regarded as an invaluable resource to

37

clinical practitioners, clinical investigators, educators, and

others from the pharmacy community.

Translating Research Into Practice ( T R ~

One of the most pressing challenges in healthcare is to
apply the knowledge that is currently available; in other
words, to close the gap between knowledge and practice.
The first round of TRIP initiatives supported development and implementation of evidence-based tools into
diverse healthcare settings. Translational efforts included
cost-effective approaches to implement smoking cessation, chlamydia screening of adolescents, diabetes care
in medically underserved areas, and treatment of respiratory distress syndrome in preterm infants. The second
round of TRIP initiatives (funded in 2000) focused on
continued development of partnerships between researcher and healthcare systems and organizations (e.g., integrated health service delivery systems, academic health
systems, purchaser groups, managed care programs including health maintenance organizations, practice networks, worksite clinics) to help accelerate and magnify
the impact of practice-based, patient outcome research in
applied settings.

atabases
AHRQ achieves its mission through a combination of
efforts, described as a research pipeline. This pipeline
of activities builds the infrastructure, tools, and knowledge for improvements in the American healthcare
system. An important part of that pipeline for pharmacy
is the maintenance of public use databases that can help
identify problems and formulate solutions to improve
pharmacotherapy. One database of particular interest is
the Medical Expenditure Panel Survey (MEPS) which
provides up-to-date, highly detailed information on how
Americans as a group, as well as segments of the population, use and pay for healthcare. This ongoing survey
of about 10,000 households and 24,000 individuals also
studies insurance coverage and other factors related to
access to healthcare. AHRQ encourages investigators to
write applications that analyze the MEPS data.

Todays AHRQ has an annual budget of $270 million for

fiscal year 2001, with approximately 80% awarded as
grants and contracts to researchers at universities and
other institutions across the country. The remaining 20%
is allocated to intramural research and administrative
support. The agency is administratively located within the

Agency for Healthcare Research and Quality

38

Department of Health and Human Services (HHS), where

it reports lo the Secretary of HHS through the Undersecretary for Health. Virtually every topic of interest to
AHRQ has a pharmacotherapy component, and virtually
every topic of interest to the pharmacothcrapy community
fits within a research priority of AHRQ.
New research investigators might first consider applying for a sniall grant which funds up to $lOO,OOO total
costs. Investigators who havc a clinical degree or a rcsearch doctoral degree and who are no more than five
years out of thcir latest research training experience might
consider applying for an Independent Scientist Award
(K02). Individuals with a clinical doctoral degree, who
have identified a mentor with extensive research experience, and are willing to spend a minimum of 75% of fulltime professional effort conducting research and developing a research career during the award might consider
applying for a Mentored Clinical Scientist Award (K08).
The agency also sponsors dissertation grants for students
working on their doctoral degrees.
Opportunities are numerous for collaboration between
AHRQ and pharmacotherapy investigators, educators,
practitioners, and administrators. Potential collaborators
are encouraged to contact AHRQ to initiate discussions
on topics of interest. Two agency publications are particularly useful in describing researchable questions and
methodologies: The Outcome of Outcomes Research at
AHCPR and Greatest Hits of Outcomes Research at

AHCpR,

r6,71

The agency is committed to a research

agenda that i \ user driven and welcome5 contacts from
the pharmacothcrapy community on topics of healthcare
quality, cost, and effectiveness.
1

1. Tlzr Omnibus Budget Reconciliation Act of 1989 (Public

Law 101-239), Part A, Section 901 (b).
2. Eiscnberg, J.M. Health services research in a marketoriented healthcare system. Health Aff. 1998, 17 (l), 98I 08.
3. Kohn, L.T.; Corrigan, J.M.; Donaldson, M.S. To Err i s
Humun: Building u SaJer Health System; Kohn, I,.T.,
Corrigan. J.M., Davidson, M.S., Eds.; Institute of Medicine, National Acadcmy Press: Washington. DC, 1999.
4. The Presidents Advisory Commission on Consumer
Protection and Quality in the Healthcare Industry. In
Quality First: Better Heulthcare ,for All Americans. Final
Report to the Pre.sident of the United States; U.S.
Government Printing Office: Washington, DC, March
1998 (GPO 017-012-00396-6).
5 . Woosley, R.L. Centers for education and research in
therapeutics. Clin. Pharmacol. Ther. 1994, 55, 249 -255.
6. Tunis, S.; Stryer, D. The Outcome oJ0utcome.r Research at
AHCPR; March 1999 (AHCPR Publication # 99-R044).
7. AHRQ. Selected Grc>ate.stHits of Outcomes Research at
AHCPR; March, 1999 (AHCPR Publication #99-R043).

PROFESSIONAL DEVELOPMENT

Idaho State University, Pocatello, Idaho, U.S.A.

I
Commuuity pharmacy practitioners have provided ambulatory care services to their customers for years. However,
more students who graduated with advanced degrees
since the 1980s have moved from the traditional dispensing role to providing direct ambulatory care patient
services. Pursuing this patient care role in ambulatory
care and primary carc settings has increased job opportunities, positioned pharmacists in patient care areas, and
changed the expectations and duties of pharmacists. This
growth in clinical pharmacy careers has also pushed
rccent graduates and those seeking employment in this
arena to pursue further training and education.
Integration of pharmacists with various disciplines of
medicine offers many benefits to thc health care system
and the paticnt, including lower costs and improved
health o ~ t c o m e s . " Pharmacists
~~~
have also ventured
away from the team approach to become more independent, which has lead to the same benefits of improved health outcomes and cost savings.12' Whether
integrated into team approach, or operating independently, pharmacists working in ambulatory and primary
care have evolved slowly. This chapter discusses these
various careers, including typical work settings and job
activities. The type of degree, training, salary, and experience, in addition to long-term growth potential, is
also discussed. Finally, to give more insight as to what
these clinical sites might be like, descriptions of various
sites are given.

The job activities, range of careers, and work cettings for

ambulatory care pharmacists vary as much as disease

Encycloprdia of Clinicul Pharmacy

DOI: 10.108I/E-ECP 120006261
Copyright Q 2003 by Marcel Dekkcr, Iiic. All rights rcscrvcd

states. However, most duties required of ambulatory care

pharmacists incorporate three to four components. These
include clinical, distributive, and administrative duties,
and sometimes a teaching or academic r01e.l~'
To expand on these jot) activities, a survey of pharmacists who work in ambulatory care positions was conducted, and it was reported that 4S% of the pharmacist's time was spent performing distributive functions,
while 30% clinical and 21% of the pharmacist's time
was spent performing administrative activities. Distributive functions of these pharmacists may be defined
as filling and dispensing prescriptions, as well prcparing
intravenous medications. The clinical portion of ambulatory care pharmacists includes a variety of activities,
such as monitoring patient outcomes and compliance,
conducting specialized clinics, providing therapeutic
drug monitoring services and, in some settings, practicing independently with prescriptive authority. Pharmacists who have been included on multidisciplinary care
teams or work at teaching hospitals may have a rcsponsibility to teach students, residents, and kllows about
various aspects of drug and disease state management.
Responses of this survey also indicated that approximately one-half of the pharmacists worked in conjunction with a physician or a nurse on an interdisciplinary ambulatory care team and that the medical staff
and senior management were very supportive of having
pharmacists o n these teams.
The aforementioned specialty clinics allow pharmacists to have an enormous impact on paticnt care and
a varicty of career opportunities. Pharmacists may be
expected to participate on a team in the multidisciplinary
approach to patient care, or may need to act indcpendently in disease-specific clinics. The Veterans Affairs
Medical Centers (VAMCs) have been leaders in the area
of a multidisciplinary approach to health care, and
pharmacists have been involved on these teams or
a long time. In a study conducted to determine the in-

39

Ambulatory CarePrimary Care, Clinical Pharmacy Careers in

40

volvement of clinical pharmacy services in 50 of the

VAMCs specialty ambulatory clinics, it was found that
310 of the 401 (77%) specialty clinics were staffed with
a clinical pharmacist and 144 (36%) were managed by
pharmacists. These clinics covered a variety of disease
states, including congestive heart failure, anticoagulation, lipid management, geriatrics, diabetes, and therapeutic drug
The work settings for pharmacists in ambulatory and
primary care clinics also vary. More recently, for example, pharmacists can be found in private physician
offices or large teaching hospitals. Anywhere ambulatory
care is being provided by physicians, nurse practitioners,
or physician assistants, there is opportunity for pharmacist involvement.

EGREE, TRAINING, EXPERIENCE,

Since the push and support for an entry-level Doctor

of Pharmacy degree by the American Association of
Colleges of Pharmacy in 1992, the majority of colleges
of pharmacy in the United States have been converting
from the Bachelor of Science degree. One of the goals
in switching to the Doctor of Pharmacy degree is for
the colleges of pharmacy to produce patient care
providers rather than medication dispensers. Because
providing patient care is one of the major activities of
ambulatory care pharmacists, the majority of graduates
have come from an entry-level Doctor of Pharmacy
program. Others, however, have returned to school for
additional education to gain the knowledge needed to
move into the clinical setting and manage the diversity
of disease states.
For many ambulatory care pharmacists. training does
not end at graduation with acceptance of the degree.
Additional training in residency or fellowship for 1 to 2
years is sometimes completed to obtain more clinical
experience in patient care as well as to develop a deeper
knowledge base. In a 1995 survey of pharmacists practicing in an ambulatory care setting, 67410 of the 99 respondents indicated that they had residency training and
21% had fellowship training. Forty-six percent of respondents also specified that they had received board
certification.[61
New graduates who select a career in ambulatory care
pharmacy may decide to complete a l-year general
pharmacy practice residency program or to choose a
specialized residency in ambulatory care or primary
care. The invaluable experience gained in residency pro-

grams provides guidance and practical training to pharmacists who are seeking more education and skills to
provide patient care. These programs are offered in a
variety of work settings from VAMCs and large teaching hospitals to smaller family medicine groups and
community pharmacies.
Although the majority of ambulatory care pharmacists
have chosen the route of the Doctor of Pharmacy degree
and residency, it is not the only course to becoming
an ambulatory care pharmacist. Some pharmacists who
have been practicing several years have grown and
established positions in ambulatory care without residency or fellowship training. However, many institutions require that they have continuing education to
practice in an ambulatory care setting with a team or
independently, and one means of continuing education
is through certificate programs. Many certificate programs that are available will teach specific disease state
management such as anticoagulation, diabetes, or asthma
care. However, other certificate programs may be more
inclusive, covering a broader spectrum of ambulatory
care. [71
Salary range for pharmacists practicing in an ambulatory care setting varies depending on geographic region, years in the work force, and board certification
status. However, the median salary in 1995 was S53,500
(average, $55,861; range, $35,000-$90,000), with a higher salary reflective of more years employed.[61

GROWTH AND LONG-TER

OPPORTUNITIES
Since the 1990s, clinicians in the fields of ambulatory
care and primary care have embraced pharmacists as
colleagues and as an invaluable source of information.
This acceptance has lead to an increase in demand of
pharmacists in the ambulatory care arena in several
capacities. First, the educational system has experienced
the need to increase the education of students in this area,
thus producing more students that choose paths in
ambulatory care. Second, pharmacists have been dedicating themselves to improving patient outcomes in primary
and ambulatory care, which has lead to a tremendous
growth and need for pharmacists in this area.
As it is evident that this field is growing, the question
arises as to the longevity of these positions. Many
pharmacists that are practicing in ambulatory care have
created their own positions. Since the mid-1980s and
early 1990s, many of these pharmacists have moved from
dispensing to the clinical role. Therefore, pharmacists

41

Ambulatory Careprimary Care, Clinical Pharmacy Careers in

who have been in ambulatory care several years are some

of the first to experience this long-term job stability.
However, as the goals for health care continue to move
toward more cost-effective ways to administer better
health care, pharmacists continue to prove themselves
to fit this equation. Thus, pharmacists will most likely
continue to be in these positions for quite some time.

One benefit of practicing as an ambulatory care pharmacist is that there are a variety of practice settings. These
practice sites vary from physician office buildings to
physician residency training programs, as well as large
hospitals and retail pharmacies.
One example is that of a private physicians office.
Studies have been performed to determine the impact of
having a pharmacist providing pharmaceutical care in a
physicians office.18] In this scenario, pharmacists usually
have unlimited access to patient information and may
have their own office or exam room to evaluate and
educate patients. The pharmacist may see these patients
independently of the physician or evaluate the patient for
pharmaceutical issues before the physician sees them.
Other services may be available at these offices such as
a laboratory or radiological services, depending on size
and specialty of the office.
Another model that may be used to integrate pharmacists into ambulatory care settings is that of a university-based family practice center or residency training program.[9J In this setting, the pharmacist typically
works at a larger physician training program and teaching clinic. The pharmacist usually has patient care duties such as specialty clinics, medication refill services,
or other consultative services. However, in this environment, the pharmacists also have obligations to teach
and evaluate the medical residents in both didactic and
clinical situations. This type of position is sometimes
affiliated with higher academic institutions, and clinical
duties may need to be balanced with administrative, research, or teaching obligations.
Other traditional sites are changing the way that
pharmacists see and educate patients. More hospitals are
moving to outpatient treatment programs and becoming involved in the multidisciplinary approach to ambulatory care patients, and practice sites for pharmacists
are moving from the central pharmacy to walk-in or
ambulatory care clinics and even home care teams.
These opportunities have allowed pharmacists who
traditionally process orders and mix intravenous medi-

cations to become involved in the treatment decisions

for patients.
Retail pharmacy is also making an effort to get pharmacists out from behind the counter by establishing a
variety of clinics in the retail setting. Some pharmacists
are providing pharmaceutical care, such as working in
conjunction with physician offices to counsel newly diagnosed diabetic patients on the proper use of glucometers and insulin injections, whereas others work more
independently, offering services in durable medical equipment, home infusion, and home oxygen.
The progress in ambulatory care has not always been a
clear road. Many barriers have risen along the way that
have prevented pharmacists from being accepted in the
clinical community as a patient care provider. Some clinicians still view pharmacists as dispensers of medications and believe patient care is not within the scope
of a pharmacists practice. In some cases, this barrier
has been surpassed in settings such as VAMCs and
HMOs, where a capitated health care system is practiced. Pharmacists have saved these institutions money
as well as improved health outcomes, acting not as dispensers of medication, but as clinicians. In addition, the
pharmacy profession itself has in some respects inhibited its own growth. Large retail pharmacy chains whose
salaries are significantly more than that of an ambulatory care pharmacist, absorb a large portion of graduates
that may desire to pursue a career in ambulatory care but
are attracted to a higher salary. However, the future
for ambulatory care pharmacists appears brighter as legislative change is looking to recognize pharmacists as
providers and reimburse them for providing pharmaceutical care.

CONCLUSION
As the need for change in the profession of pharmacy
has evolved since the 1990s, pharmacy schools have responded by producing a well-rounded practitioner and
provider of pharmaceutical care. More graduates are
choosing to gain patient care skills and training in ambulatory care residency or fellowship programs, allowing them to be focused practitioners and teachers. The
future for pharmacists in the area of ambulatory care
looks bright as pharmacists lobby to be recognized as
providers and to be reimbursed for providing pharmaceutical care. Finally, as pharmacists continue to
demonstrate that their clinical services improve patient
outcomes and decrease overall health care costs, jobs in
the ambulatory care setting will continue to expand to

Ambulatory Cardlrimary Care, Clinical Pharmacy Careers in

42

other venues, allowing pharmacists to accomplish what

they were trained to do.

4.

5.
6.

McMullin, S.T.; Hennenfent, J.A.; Rithie, D.J.; Huey,

W.Y.; Lonergan, T.P.; Schaiff, R.A.; Tonn, M.E.; Bailey,
T.C. A prospective, randomized trial to assess the cost
impact of pharmacist-initiated interventions. Arch. Intern.
Med. 1999, 1 5 Y , 2306- 2309.
Gattis, W.A.; Hasselblad, V.; Whellan, D.J.; OConnor,
C.M. Reduction in heart failure events by the addition of a
clinical pharmacist to the heart failure management team:
Results of the Pharmacist in Heart Failure Assessment
Recommendation and Monitoring (PHARM) Study. Arch.
Intern. Med. 1999, 159, 1939 1945.
Chiquette, E.; Amato, M.G.; Russey, H.T. Comparison of
an antiocogulation clinic with usual care. Arch. Intern.
Med. 1998, 158, 1641-1647.

7.

Reeder, C.E.; Kozma, C.M.; OMalley, C. ASHP Survey of

ambulatory care responsibilities of pharmacists in integrated health systems-1997. Am. J. Health-Syst. Pharm.
1998, 55, 35-43.
Carter, B.L. Clinical pharmacy in disease specific clinics.
Phamacotherapy 2000, 20 (10 Pt 2), 273s-277s.
Anastasio, G.D.; Shaughnessy, A.F. Salary survey of ambulatory care clinical pharmacists. Pharmacotherapy 1997,
17 (3), 565--568.
Jannsen, R.K.; Murphay, C.M.; Kendzierski, Q.L.; Brown,
D.H.; Carter, B.L.; Furmaga, E M . ; Schoen, M.D.; Woker,
D.R. Ambulatory care certificate program for pharmacists.
Am. J. Health-Syst. Pharm. 1996, 53, 1018 1023.
Campbell, R.K.; Sadie, B.A. Providing pharmaceutical
care in a physician office. J. Am. Pharm. Assoc. 1998, 38,
495- 499.
Lilley, S.H.; Cummings, D.M.; Whitley, C.W.; Pippin, H.J.
Intergration of a pharmacotherapy clinic in a universitybased family practice center. Hosp. Pharm. 1998, 33,
1105-1 110.
~

8.

9.

PROF ESSl 0NAL ORGAN IZATIO NS

American College of Clinical Pharmacy,

Kansas City, Missouri, U.S.A.

ershi

The American College of Clinical Pharmacy (ACCP) was

founded in 1979 when 29 clinical pharmacists-organized
largely by Donald C. McLeod, M.S.-gathered in Kansas
City, Missouri, with a common goal: to promote the
rational use of medications in society by forming an
organization dedicated to and focused on advancing the
cutting-edge of clinical pharmacy practice and research.
Those ideals held by ACCPs founding members still find
themselves in the Colleges mission:
ACCP is a professional and scientific society that provides leadership, education, advocacy, and other resources
enabling clinical pharinacists to achieve excellence in
practice and research.

TI
Only two years after its founding, ACCP created its
Research Institute in 1981 to advance pharmacotherapy
through support and promotion of research, training, and
educational programs. Through 2000, this has largely
taken the form of a number of Research Awards that
support specific research projects conducted by College
members in a variety of therapeutic areas, and Fellowships that provide for the stipends of postgraduate clinical
pharmacists in an intensive research training experience.
Both types of programs are available to ACCP members
on a competitive basis.
Also in 1981. Russcll R. Miller, Ph.D., founded the
journal Phurmucotherupy as a publication dedicated to
human pharmacology and drug therapy. When first established, Pharmucotherupy was not affiliated with any
medical or pharmacy associations. In 1988, ACCP adopted
Pharinucotherupy as its official journal, and in 1994,
ACCP acquired the journal. Now a monthly publication,
Phurmucotherupy publishes a complementary array of original clinical research and evidcnce-based reviews in the
broad field of pharmacotherapy and clinical pharmacology.
Encyrlopdiu of Cliniral Pizarmacj

D01: 10.1081/E-ECP 120006306

Copyright 0 2003 by Marcel Dekker, Inc. All rights reserved

As of the end of 2001, ACCP had approximately 7000

members, located mostly in the United States and Canada.

ACCP members can be found in all practice venues,
including ambulatory clinics and community pharmacies,
community hospitals, the pharmaceutical industry, pharmacy and medical school faculties, university hospitals,
and VA and military hospitals. More than 80% of ACCP
members hold the Pharm.D. degree, 70% have completed
a postgraduate residency, and 25% have complcted a
research fellowship training program. Approximately
25% of ACCP members are certified in one or more of
the specialty practice areas recognized by the Board of
Pharmaceutical Specialties (BPS; i.c., Nuclear Pharmacy,
Nutrition Support, Oncology, Pharmacotherapy, Psychiatry). Consistent with one of ACCPs founding tenets-to
promote the rational use of medications in societyCollege members directly assume responsibility for the
drug therapy of individual patients through collaborative
practice agreements with physicians; regularly consult
with and advise physicians, other health professionals,
and patients regarding drug therapy; serve on key institutional or other committees that oversee the medication
use process; and teach pharmacy or other hcalth profession students. In addition, many ACCP members are
responsible for conducting basic, clinical, health services,
economic, or other applied research. This research, for
example, may involve clinical trials of new drug entities,
pharmacokinctic and pharmacodynamic studies in normal
volunteers and patients, pharmacoeconomic evaluations
of drug therapies, and health services research to examine the impact of pharmacy services.
The practice and research interests of ACCP members
span the broad array of pharmacothcrapy. As one way to
provide for the unique needs of clinical pharmacists with
diverse interests, ACCP currently includes approximately
20 Practice and Research Networks (PRNs). The PRNs
form special interest groups within the College jn areas
ranging from Ambulatory Care to Infectious Diseases to
Womens Wealth.
43

American College of Clinical Pharmacy (ACCP)

44

JO
E~u~at~on
ACCP holds three major scientific and/or educational
meetings each year. The ACCP Annual Meeting, held in
late-October or early-November, and the Spring Practice
and Research Forum, held in April, include a variety of
educational symposia as well as poster or platform
presentations of original research. Both meetings include
educational and networking sessions conducted by the
Colleges PRNs. The ACCP Recruitment Forum takes
place at the Annual Meeting and provides an opportunity
for employers and prospective applicants to interview.
Recruitment On-Line, a year-round job listing service, is
available on the Colleges web site.
Each year, ACCP also conducts its Updates in
Therapeutics, designed as both a comprehensive review
of therapeutics and as a preparatory course for clinical
pharmacists planning to sit for BPS specialty certification
in Pharmacotherapy, Nutrition Support, Oncology, or
Psychiatry. ACCP is expanding its use of technology to
facilitate distance learning. ACCP educational programs
will be increasingly available through the Colleges web
site at www.accp.com.
In April 1999, ACCP partnered with the European
Society of Clinical Pharmacy (ESCP) to co-host the first
International Congress on Clinical Pharmacy in Orlando,
Florida. With a theme of Documenting the Value of
Clinical Pharmacy Services, the Congress was attended
by more than 1300 pharmacists from 51 countries.]
ACCP and ESCP plan to organize a second International
Congress in 2004.

ublications
In addition to Pliarzacotherapy, publications produced
by ACCP include the Pharmacotherapy Selj-Assessment
Program (PSAP) and the Colleges annual Directoy of
Residencies and Fellowships. In addition to its use as a
general professional development tool, PSAP is approved
by BPS for use by Board Certified Pharmacotherapy
Specialists (BCPS) in obtaining their required recertification. With publication of its fourth edition (PSAP-IV) in
2001, this modular-based program is available in both
hardcopy and Internet versions. The ACCP Directoiy of
Residencies and Fellowsliips provides a comprehensive
index and description of postgraduate training opportunities offered by ACCP members. It is published in the
fall of each year to assist students and residents in their
career development. Other publications available from
ACCP are described on the Colleges web site.

rofesional Leadership and Advocacy

ACCP participates in several coalitions with other
national organizations, including the Council on Credentialing in Pharmacy, the Joint Commission of Pharmacy Practitioners, the Alliance for Pharmaceutical Care,
and the Pharmaceutical Sciences Consortium. In general,
ACCPs advocacy efforts are focused on the federal
government, with the overall goal of better enabling
clinical pharmacists to provide patient care and perform research.
A bibliography and reprints of ACCP white papers,
position statements, and guidelines are available on the
Colleges web site. These include two comprehensive
reviews of published literature that document the value of
clinical pharmacy

GOVERNANCE
ACCP is governed by an 11-person Board of Regents,
elected from and by the Colleges members. The
President of the College serves as chair of the Board of
Regents. Members of the 2001 Board of Regents include:
President: Barry L. Carter, Pharm.D., FCCP, BCPS
President-Elect: Bradley A. Boucher, Pharm.D.,
FCCP, BCPS
Past President: Thomas C. Hardin, Pharm.D., FCCP,
BCPS
Secretary: J. Herbert Patterson, Pharm.D., FCCP,
BCPS
Treasurer: Marsha A. Raebel, Pharm.D., FCCP, BCPS
Regents: Betty J. Dong. Pharm.D.; Julie A. Johnson,
Pharm.D., FCCP, BCPS; Mary Lee, Pharm.D., FCCP,
BCPS; Michael Maddux, Pharm.D., FCCP; Ralph H.
Raasch, Pharm.D., FCCP, BCPS; and David R. Rush,
Pharm.D., BCPS

REFERENCES
1. Proceedings of the First International Congress on Clinical
Pharmacy. Pharmacotherapy 2000, 20, 233s-3468.
2. Willett, M.S.; Bertch, K.E.; Rich, D.S.; Ereshefsky, L.
Prospectus on the economic value of clinical pharmacy services. Pharmacotherapy 1989, 9. 45-56.
3. Schumock, G.T.; Meek, P.D.; Ploetz, P.A.; Vermeulen,
L.C. Economic evaluations of clinical pharmacy services-1988- 1995. Pharmacotherapy 1996, 16, 11881208.

PROFESSIONAL ORGANIZATIONS

American Council on Pharmacwitical Education,

Chicago, Illinois, U.S.A.

The American Council on Pharmaceutical Education

(ACPE), located at 31 I W. Superior Street, Suite 512,
Chicago, Illinois 606 10-3537, is the national agency for
accreditation of professional degree programs in pharmacy and providers of continuing pharmaceutical education including ccrtiGcate programs in pharmacy. The
ACPE was established in 1932 for accreditation of
preservice (entry-levcl) pharmacy education. Accreditation standards reflect profcssional and educational
qualities identified by ACPE as cssential to quality
professional programs at colleges and schools of pharmacy. Standards are established through a comprehensive
and broadly bascd procedure that provides opportunities
for contributions from the community of interests affected
by the accreditation process.

VIE

The first ACPE standards, devcloped betwecn 1932 and

1937, called for sweeping changes in pharmaceutical
education. These standards required the complction of a
four-year course of study in order to attain the baccalaureate degree in pharmacy. The standards were published in 1937 and were subsequently revised during the
1940s and early 1950s. In the 1960s, revision of the standards led to the incorporation of a five-year baccalaureate
in pharmacy program and a doctor of pharmacy program
which involved a four-year professional program that
was preceded by two ycars of preprofessional studics. In
the mid- 1970s, standards for two separate entry-levcl,
professional programs, the baccalaureate in pharmacy
program and the doctor of pharmacy program were developed. In addition, professional practice experiences
were incorporated into thc curriculum for the first time.
Encyclopedia of Clinical Pharmacy
DOI: 10. IOXl/E-ECP 120006109
Copyright 0 2003 by Marcel De&er, Inc. All rights reserved

The revisions of the 1980s expanded upon curricular

expectations for the doctor of pharmacy program leading
to grcater emphasis on curricular and programmatic outcomes. In 1989, ACPE issucd its intention to propose
new standards that would merge thc two programmatic
standards with a focus on a doctor of pharmacy program.
The new accreditation standards and guidelines for the
professional program in pharmacy leading to the Doctor
of Pharmacy degree (Standards 2000) werc adopted June
14, 1997. Implementation Procedures for thcsc ncw accreditation standards became effective on July 1, 2000,
in accord with a stated transition pcriod.

Requirements for continued pharmaceutical education

began in the early 1970s, when State Boards of Pharmacy
began requiring licensed pharmacists to participatc in
continuing pharmaceutical education activities. Between
1972 and 1974, the American Association of Colleges of
Pharmacy and the American Pharmaceutical Association
convened a task force to discuss issues related to the
continued competence in pharmacy practice. In 1974, the
Board of the American Pharmaccutical Association
recommended that ACPE initiate accreditation of continuing pharmaceutical education. Consequently, ACPE
began the accreditation of providers of continuing pharmaceutical cducation in 1975. Participation in continuing
education programs earned through an ACPE-accrcdited
provider is accepted ior licensure renewal by all state
boards of pharmacy requiring continuing education. The
symbol used by the ACPE to designate that a continuing
education provider is accreditcd is

In 1998, the profession chargcd ACPE to devclop

standards for certificate programs. A ccrtificate program
is a structured continuing education experience that is
narrower in focus and shorter in duration than a degree
45

Biopharmaceutics

Table 4

91

Drug absorption in the gastrointestinal tract (Continued)

Function

Affect on drug absorption

The rectum is about 15 cm long, ending at the anus.

In the absence of fecal material, the rectum has a
small amount of fluid, (about 2 m) with a pH about 7.
The rectum is perfused by the superior, middle, and
inferior hemorrhoidal veins. The inferior hemorrhoidal
vein (closest to the anal sphincter) and the middle
hemorrhoidal vein feed into the vena cava and back to
the heart. The superior hemorrhoidal vein joins the
mesenteric circulation, which feeds into the hepatic
portal vein and then to the liver.

Drug absorption may be variable depending upon the

placement of the suppository or drug solution within
the rectum. A portion of the drug dose may be
absorbed via the lower hemorrhoidal veins, from
which the drug feeds directly into the systemic
circulation; some drug may be absorbed via the
superior hemorrhoidal veins, which feeds into the
mesenteric veins to the hepatic portal vein to the
liver, and metabolized prior to systemic absorption.

Anatomic area
Rectum

Some drugs may be absorbed into the lymphatic

circulation through the lacteal or lymphatic vessels under
the microvilli. Absorption of drugs through the lymphatic
system bypasses the first-pass effect due to liver
metabolism, because drug absorption through the hepatic
portal vein is avoided. The lymphatics are important in the
absorption of dietary lipids and may be partially
responsible for the absorption for some lipophilic drugs
such as bleomycin or aclarubicin which may dissolve in
chylomicrons and be systemically absorbed via the
lymphatic system.

Effect of food and other factors

on GI drug absorption
Digested foods may affect intestinal pH and solubility of
drugs. Food effects are not always predictable. The
absorption of some antibiotics (e.g., penicillin, tetracycline) is decreased with food, whereas other drugs (e.g.,
griseofulvin) are better absorbed when given with food
containing a high fat content. Food in the GI lumen
stimulates the flow of bile. Bile contains bile acids. Bile
acids are surfactants are involved in the digestion and
solubilization of fats, and increases the solubility of fatsoluble drugs through micelle formation. For some basic
drugs (e.g., cinnarizine) with limited aqueous solubility,
the presence of food in the stomach stimulates
hydrochloric acid secretion, which lowers the pH, causing
more rapid dissolution of the drug and better absorption.
Generally, the bioavailability of drugs is better in
patients in the fasted state and with a large volume of water
(Fig. 5). However, to reduce GI mucosal irritation, drugs
such as erythromycin, iron salts, aspirin, and nonsteroidal
anti-inflammatory agents (NSAIDs) are given with food.
The rate of absorption for these drugs may be reduced
in the presence of food, but the extent of absorption may be
the same.

The drug dosage form may also be affected by food. For

example, enteric-coated tablets may stay in the stomach
for a longer period of time because food delays stomach
emptying. If the enteric-coated tablet does not reach the
duodenum rapidly, drug release and subsequent systemic
drug absorption are delayed. In contrast. enteric-coated
beads or microparticles disperse in the stomach, are less
affected by food, and demonstrate more consistent drug
absorption from the duodenum.
Food may also affect the integrity of the dosage form,
causing an alteration in the release rate of the drug.
For example, theophylline bioavailability from Theo-24
controlled-release tablets is much more rapid (7)
when given to a subject in the fed rather than fasted
state (Fig. 6).
Some drugs, such as ranitidine, cimetidine, and
dipyridamole, after oral administration produce a blood
concentration curve consisting of two peaks. This
double-peak phenomenon is generally observed after
the administration of a single dose to fasted patients. The
rationale for the double-peak phenomenon has been
attributed to variability in stomach emptying, variable
intestinal motility, presence of food, enterohepatic
recycling, or failure of a tablet dosage form. For a
drug with high water solubility, dissolution of the drug
occurs in the stomach, and partial emptying of the drug
into the duodenum will result in the first absorption peak.
A delay in stomach emptying results in a second
absorption peak as the remainder of the dose is emptied
into the duodenum.
Diseases such as Crohns disease that alter GI
physiology and corrective surgery involving peptic ulcer,
antrectomy with gastroduodenostomy and selective
vagotomy may potentially affect drug absorption. Drug
absorption may be unpredictable in many disease
conditions. Drugs or nutrients or both may also affect
the absorption of other drugs. For example, propantheline

Biopharmaceutics

92

54
34
r-

.4
&L

!4
4
4

5 6 4 !

r-

? % !

6 4 !

Fig. 5 Mean plasma or serum drug levels in healthy, fasting human volunteers ( n = 6 in each case) who received single oral doses of
aspirin (650 mg) tablets, erythromycin stearate (500 mg) tablets, amoxicillin (500 mg) capsules, and theophylline (260 mg) tablets,
together with large. (From Welling P.G.; Drug Bioavailability and Its Clinical Significance. Progress in Drug Metabolism, Vol. 4;
Bridges K.W.; Chassea, VD LF. Eds.; Wiley; London, 1980.)

bromide is an anticholinergic drug that slows stomach

emptying and motility of the small intestine and may
reduce stomach acid secretion. Grapefruit juice was found
to increase the plasma level of many drugs due to
inhibition of their metabolism in the liver.

suspension, suppository), 2 ) the nature of the excipients

in the drug product, 3) the physicochemical properties
of the drug molecule, and 4) the route of drug
administration.

Disintegration

Biopharmaceutic considerations in the design and

manufacture of a drug product to deliver the active
drug with the desired bioavailability characteristics
include: 1) the type of drug product (e.g., solution,

Immediate release, solid oral drug products must rapidly

disintegrate into small particles and release the drug. The
United States Pharmacopoeia (USP) describes an official
tablet disintegration test. The process of disintegration
does not imply complete dissolution of the tablet and/or
the drug. Complete disintegration is defined by the USP as
that state in which any residue of the tablet, except
fragments of insoluble coating, remaining on the screen of

Biopharmaceutics

3t

93

# 8

of the rate of drug diffusion from the surface to the bulk of

the solution. In general, drug concentration at the surface
is assumed to be the highest possible, i.e., the solubility of
the drug in the dissolution medium. The drug concentration C is the homogeneous concentration in the bulk
solution which is generally lower than that in the stagnant
layer immediate to the surface of the solid. The decrease in
concentration across the stagnant layer is called the
diffusion gradient
dCldt = DA(CS - C)h

!,

&!

,4

,6

35

54

Fig. 6 Theophylline serum concentration in an individual

subject after a single 1500 mg dose of Theo-24 taken during
fasting, period during which this patient experienced nausea,
repeated vomiting, or severe throbbing headache. The pattern of

drug release during the food regimen is consistent with dosedumping. (From Ref. 7.)
the test apparatus in the soft mass have no palpably firm
core. The USP provides specifications for uncoated
tablets, plain coated tablets, enteric tablets, buccal tablets,
and sublingual tablets. Exempted from USP disintegration
tests are troches, tablets which are intended to be chewed,
and drug products intended for sustained release or
prolonged or repeat action.
Disintegration tests allow for precise measurement of
the formation of fragments, granules, or aggregates from
solid dosage forms, but do not provide information on the
dissolution rate of the active drug. The disintegration test
serves as a component in the overall quality control of
tablet manufacture.

Dissolution
Dissolution is the process by which a chemical or drug
becomes dissolved in a solvent. In biologic systems, drug
dissolution in an aqueous medium is an important prior
condition of systemic absorption. The rate at which drugs
with poor aqueous solubility dissolve from an intact or
disintegrated solid dosage form in the GI tract often
controls the rate of systemic absorption of the drug. Thus,
dissolution tests are discriminating of formulation factors
that may affect drug bioavailability.
As the drug particle dissolves, a saturated solution
(stagnant layer) is formed at the immediate surface around
the particle. The dissolved drug in the saturated solution
gradually diffuses to the surrounding regions. The overall
rate of drug dissolution may be described by the NoyesWhitney equation which models drug dissolution in terms

where, dCldt = rate of drug dissolution, D = diffusion rate

constant, A = surface area of the particle, CS = drug
concentration in the stagnant layer, C = drug concentration in the bulk solvent, and h = thickness of the
stagnant layer.
The rate of dissolution, (dCldt) X (UA), is the amount
of drug dissolved per unit area per time (e.g., g/cm2 per
min).
The Noyes-Whitney equation shows that dissolution
rate is influenced by the physicochemical characteristics of
the drug, the formulation, and the solvent. In addition, the
temperature of the medium also affects drug solubility and
dissolution rate.

~iubility,pH, an
The natural pH environment of the GI tract varies from
acidic in the stomach to slightly alkaline in the small
intestine. Drug solubility may be improved with the
addition of acidic or basic excipients. Solubilization of
aspirin, for example, may be increased by the addition of
an alkaline buffer. Controlled release drug products are
nondisintegrating dosage forms. Buffering agents may be
added to slow or modify the release rate of a fastdissolving drug in the formulation of a controlled release
drug product. The buffering agent is released slowly rather
than rapidly so that the drug does not dissolve immediately
in the surrounding GI fluid. Intravenous drug solutions are
difficult to prepare with drugs that have poor aqueous
solubility. Drugs that are physically or chemically unstable
may require special excipients, coating or manufacturing
process to protect the drug from degradation.

Stability, pH, and Dru

rptio

The pH-stability profile is a plot of reaction rate constant

for drug degradation versus pH and may help to predict if

94

Biopharmaceutics

some of the drug will decompose in the GI tract. The

stability of erythromycin is pH-dependent. In acidic
medium, erythromycin decomposition occurs rapidly,
whereas at neutral or alkaline pH the drug is relatively
stable. Consequently, erythromycin tablets are enteric
coated to protect against acid degradation in the stomach.
In addition, less soluble erythromycin salts that are more
stable in the stomach have been prepared.

Particle
The effective surface area of the drug is increased
enormously by a reduction in the particle size. Because
drug dissolution is thought to take place at the surface of
the solute, the greater the surface area, the more rapid the
rate of drug dissolution. The geometric shape of the drug
particle also affects the surface area, and during
dissolution the surface is constantly changing. In
dissolution calculations, the solute particle is usually
assumed to have retained its geometric shape.
Particle size and particle size distribution studies are
important for drugs that have low water solubility. Particle
size reduction by milling to a micronized form increased
the absorption of low aqueous solubility drugs such as
griseofulvin, nitrofurantoin, and many steroids. Smaller
particle size results in an increase in the total surface area
of the particles, enhances water penetration into the
particles, and increases the dissolution rates. With poorly
soluble drugs, a disintegrant may be added to the
formulation to ensure rapid disintegration of the tablet
and release of the particles.

Fig. 7 Comparison of mean blood serum levels obtained with

chloramphenicol palmitate suspensions containing varying ratios
of 01 and p polymorphs, following single oral dose equivalent.
(From Ref. 9.)

change in crystal structure of the drug may cause cracking

in a tablet or even prevent a granulation to be compressed
into a tablet requiring reformulation of the product. Some
drugs interact with solvent during preparation to form a
crystal called solvate. Water may form a special crystal
with drugs called hydrates, for example, erythromycin
forms different hydrates (8) which may have quite different
solubility compared to the anhydrous form of the drug
(Fig. 8). Ampicillin trihydrate, for example, was reported

Polymorphic Crystals, Solvates,

and Drug Absorption
Polymorphism refers to the arrangement of a drug in
various crystal forms (polymorphs). Polymorphs have the
same chemical structure but different physical properties,
such as solubility, density, hardness, and compression
characteristics. Some polymorphic crystals may have
much lower aqueous solubility than the amorphous forms,
causing a product to be incompletely absorbed. Chloramphenicol(9), for example, has several crystal forms, and
when given orally as a suspension, the drug concentration
in the body depended on the percentage of P-Polymorph in
the suspension. The @-form is more soluble and better
absorbed (Fig. 7). In general, the crystal form that has the
lowest free energy is the most stable polymorph.
Polymorphs that are metastable may convert to a more
stable form over time. A crystal form change may cause
problems in manufacturing the product. For example, a

'44
64

-4

'4

!4

&4

,4

34

54

Fig. 8 Dissolution behavior of erythromycin dihydrate,

monohydrate, and anhydrate in phosphate buffer (pH 7.5) at
37C. (From Ref. 8.)

Biopharmaceutics

Table 5

95

Table 6

Common excipients used in solid drug products

Excipient

Excipient

Property in dosage form

Lactose
Dibasic calcium phosphate
Starch
Microcrystalline cellulose
Magnesium stearate
Stearic acid
Hydrogenated vegetable oil
Talc
Sucrose (solution)
Polyvinyl pyrrolidone (solution)
Hy droxypropy lmethylcellulose
Titinium dioxide
Methylcellulose
Cellulose acetate phthalate

Common excipients used in oral liquid drug products

Diluent
Diluent
Disintegrant, diluent
Disintegrant, diluent
Lubricant
Lubricant
Lubricant
Lubricant
Granulating agent
Granulating agent
Tablet-coating agent
Combined with dye as
colored coating
Coating or granulating agent
Enteric coating agent

Property in dosage form

Sodium carboxymethylcellulose
Tragacanth
Sodium alginate
Xanthan gum
Veegum
Sorbitol
Alcohol
Propylene glycol
Methyl propylparaben
Sucrose
Poly sorbates
Sesame oil
Corn oil

Suspending agent
Suspending agent
Suspending agent
Thixotropic
suspending agent
Thixotropic
suspending agent
Sweetener
Solubilizing agent,
preservative
Solubilizing agent
Preservative
Sweetener
Surfactant
For emulsion vehicle
For emulsion vehicle

(From Ref. 1.)

(From Ref. 1.)

to be less absorbed than the anhydrous form of ampicillin

due to faster dissolution of the latter.

Excipients are pharmacodynamically inactive substances

that are added to a formulation to provide certain
functional properties to the drug and dosage form.
Excipients may be added to improve the compressibility
of the active drug, stabilize the drug from degradation,
decrease gastric irritation, control the rate of drug
absorption from the absorption site, increase drug
bioavailability, etc. Some excipients used in the

Table 7

manufacture of solid and liquid drug products are

listed in Tables 5 and 6. For solid oral dosage forms
such as compressed tablets, excipients may include
1) diluent (e.g., lactose), 2) disintegrant (e.g., starch),
3) lubricant (e.g., magnesium stearate), and 4) other
components such as binding and stabilizing agents.
When improperly used in the formulation, excipients
may alter drug bioavailability and possibly pharmacodynamic activity.
Excipients may affect the drug dissolution rate by
altering the medium in which the drug is dissolving or
by reacting with the drug itself. Some common
manufacturing problems that affect drug dissolution
and bioavailability are listed in Table 7. For example,

Effect of excipients on the pharmacokinetic parameters of oral drug producta

Excipients

Example

Disintegrants
Lubricants
Coating agent
Enteric coat
Sustained-release agents
Sustained-release agents (waxy agents)
Sustained-release agents (gudviscous)

Avicel, Explotab
Talc, hydrogenated vegetable oil
Hydroxypropylmethyl cellulose
Cellulose acetate phthalate
Methylcellulose, ethylcellulose
Castorwax, Carbowax
Veegum, Keltrol

"This may be concentration and drug dependent.

1= Increase, = decrease, - = no effect. k , = absorption rate constant, t,,,
drug concentration time curve.
(From Ref. 1.)

ka

tmax

t
t
t
T

c
c
c

AUC

= time for peak drug concentration in plasma, AUC = area under the plasma

96

suspending agents increase the viscosity of the drug

vehicle, but may decrease the drug dissolution rate from
the suspension. An excessive quantity of magnesium
stearate (a hydrophobic lubricant) in the formulation
may retard drug dissolution and slow the rate of drug
absorption. The total amount of drug absorbed may also
be reduced. To prevent this problem, the lubricant level
should be decreased or a different lubricant selected.
Sometimes, increasing the amount of disintegrant may
overcome the retarding effect of lubricants on
dissolution. However, with some poorly soluble drugs
an increase in disintegrant level has little or no effect
on drug dissolution because the fine drug particles are
not wetted. The general influence of some common
excipients on drug bioavailability parameters for typical
oral drug products is summarized in Table 7.
Excipients may enhance or diminish the rate and
extent of systemic drug absorption. Excipients that
increase the aqueous solubility of the drug generally
increase the rate of drug dissolution and absorption. For
example, sodium bicarbonate in the formulation may
change the pH of the medium surrounding the active
drug substance. Aspirin, a weak acid, in an alkaline
medium will form a water-soluble salt in which the drug
rapidly dissolves. This process is known as dissolution in
a reactive medium. The solid drug dissolves rapidly in
the reactive solvent surrounding the solid particle. As the
dissolved drug molecules diffuse outward into the bulk
solvent, the drug may precipitate out of solution with a
very fine particle size. The small particles have
enormous collective surface area and disperse and
redissolve readily for more rapid absorption on contact
with the mucosal surface.
Excipients may interact directly with the drug to form a
water-soluble or water-insoluble complex. If tetracycline
is formulated with calcium carbonate, an insoluble
complex of calcium tetracycline is formed that has a
slow rate of dissolution and poor absorption.
Excipients may increase the retention time of the
drug in the GI tract and therefore increase the amount
of drug absorbed. Excipients may act as carriers to
increase drug diffusion across the intestinal wall. The
addition of surface-active agents may increase wetting
as well as solubility of drugs. In contrast, many
excipients may retard drug dissolution and thus reduce
drug absorption.
Shellac used as a tablet coating, upon aging, can
slow the drug dissolution rate. Surfactants may affect
drug dissolution in an unpredictable fashion. Low
concentrations of surfactants lower the surface tension
and increase the rate of drug dissolution, whereas higher
concentrations of surfactants tend to form micelles with

Biopharmaceutics

the drug and thus decrease the dissolution rate. High

tablet compression without sufficient disintegrant may
cause poor disintegration in vivo of a compressed
tablet.

A dissolution test in vitro measures the rate and extent of

dissolution of the drug in an aqueous medium in the
presence of one or more excipients contained in the drug
product. A potential bioavailability problem may be
uncovered by a suitable dissolution method. The optimum
dissolution testing conditions differ with each drug
formulation. Different agitation rates, different medium
(including different pH), and different dissolution
apparatus should be tried to distinguish which dissolution
method is optimum for the drug product and discriminating for drug formulation changes. The appropriate
dissolution test condition for the drug product is then
used to determine acceptable dissolution specifications.
The size and shape of the dissolution vessel may
affect the rate and extent of dissolution. For example, the
vessel may range in size from several milliliters to
several liters. The shape may be round-bottomed or flat,
so that the tablet might lie in a different position in
different experiments. The amount of agitation and the
nature of the stirrer affect the dissolution rate. Stirring
rates must be controlled, and specifications differ
between drug products. Low stirring rates (SO- 100 rpm)
are more discriminating of formulation factors affecting
dissolution than higher stirring rates. The temperature of
the dissolution medium must be controlled and variations
in temperature must be avoided. Most dissolution tests
are performed at 37C.
The nature of the dissolution medium, the solubility of
the drug and the amount of drug in the dosage form will
affect the dissolution test. The dissolution medium should
not be saturated by the drug. Usually, a volume of medium
larger than the amount of solvent needed to completely
dissolve the drug is used in such tests. The usual volume of
the medium is 500- 1000 ml. Drugs that are not very water
soluble may require use of a very-large-capacity vessel
(up to 2000 ml) to observe significant dissolution. Sink
conditions is a term referring to an excess volume of
medium that allows the solid drug to continuously
dissolve. If the drug solution becomes saturated, no
further net drug dissolution will take place. According to
the USP, the quantity of medium used should be not less
than three times that required to form a saturated solution
of the drug substance.

Biopharmaceutics

Which medium is best is a matter of considerable

controversy. The preferred dissolution medium in USP
dissolution tests is deaerated water or if substantiated by
the solubility characteristics of the drug or formulation, a
buffered aqueous solution (typically pH 4-8) or dilute
HCl may be used. The significance of dearation of the
medium should be determined. Various investigators have
used 0.1 N HCl, 0.01 N HCl, phosphate buffer, simulated
gastric juice, water, and simulated intestinal juice,
depending on the nature of the drug product and the
location in the GI tract where the drug is expected to
dissolve. No single apparatus and test can be used for all
drug products. Each drug product must be tested
individually with the dissolution test that best correlates
to in vivo bioavailability.
The dissolution test usually states that a certain
percentage of the labeled amount of drug in the drug
product must dissolve within a specified period of time. In
practice, the absolute amount of drug in the drug product
may vary from tablet to tablet. Therefore, a number of
tablets from each lot are usually tested to get a
representative dissolution rate for the product. The USP
provides several official (compendia) methods for carrying
out dissolution tests of tablets, capsules and other special
products such as transdermal preparations. The selection
of a particular method for a drug is usually specified in the
monograph for a particular drug product.

BIOAVAILABILITY
BlQEQUWALE NCE
Bioavailability and bioequivalence may be determined
directly using plasma drug concentration vs. time profiles,
urinary drug excretion studies, measurements of an acute
pharmacologic effect, clinical studies, or in vitro studies.
Bioavailability studies are performed for both approved
active drug ingredients or therapeutic moieties not yet
approved for marketing by the FDA. New formulations of
active drug ingredients or therapeutic moieties must be
approved, prior to marketing, by the FDA. In approving a
drug product for marketing, the FDA must ensure that the
drug product is safe and effective for its labeled
indications for use. To ensure that the drug product
meets all applicable standards of identity, strength, quality,
and purity, the FDA requires bioavailability/pharmacokinetic studies and where necessary bioequivalence studies
for all drug products.
For unmarketed drugs which do not have full New
Drug Application (NDA) approval by the FDA, in vivo
bioavailability studies must be performed on the

97

drug formulation proposed for marketing. Essential

pharmacokinetic parameters of the active drug ingredient
or therapeutic moiety is also characterized. Essential
pharmacokinetic parameters include the rate and extent of
systemic absorption, elimination half-life, and rates of
excretion and metabolism should be established after
single- and multiple-dose administration. Data from these
in vivo bioavailability studies are important to establish
recommended dosage regimens and to support drug
labeling.
In vivo bioavailability studies are performed also for
new formulations of active drug ingredients or therapeutic
moieties that have full NDA approval and are approved for
marketing. The purpose of these studies is to determine the
bioavailability and characterize the pharmacokinetics of
the new formulation, new dosage form, or new salt or ester
relative to a reference formulation. After the bioavailability and essential pharmacokinetic parameters of the
active ingredient or therapeutic moiety are established,
dosage regimens may be recommended in support of drug
labeling.

Bioequivalent drug products are pharmaceutical equivalents whose bioavailability (i.e., rate and extent of
systemic drug absorption) does not show a significant
difference when administered at the same molar dose of
the therapeutic moiety under similar experimental
conditions, either single or multiple dose. Some pharmaceutical equivalents or may be equivalent in the extent of
their absorption but not in their rate of absorption and yet
may be considered bioequivalent because such differences
in the rate of absorption are intentional and are reflected in
the labeling, are not essential to the attainment of effective
body drug concentrations on chronic use, or are considered
medically insignificant for the particular drug product
studied [21 CFR 320.l(e)].

A generic drug product is considered bioequivalent to

the reference listed drug product (generally the currently
marketed, brand-name product with a full (NDA)
approved by the FDA) if both products are pharmaceutical equivalents and its rate and extent of systemic drug
absorption (bioavailability) do not show a statistically
significant difference when administered in the same
dose of the active ingredient, in the same chemical form,
in a similar dosage form, by the same route of
administration, and under the same experimental
conditions.

Biopharmaceutics

98

Pharmaceutical equivalents are drug products that

contain the same therapeutically active drug ingredient(s),
same salt, ester, or chemical form; are of the same dosage
form; and are identical in strength and concentration and
route of administration. Pharmaceutical equivalents may
differ in characteristics such as shape. scoring configuration. release mechanisms, packaging, and excipients
(including colors, flavoring, preservatives).
Therapeutic equivalent drug products are pharmaceutical equivalents that can be expected to have the same
clinical effect and safety profile when administered to
patients under the same conditions specified in the
labeling. Therapeutic equivalent drug products have the
following criteria: 1) The products are safe and effective;
2 ) The products are pharmaceutical equivalents containing the same active drug ingredient in the same dosage
form, given by the same route of administration, meet
compendia or other applicable standards of strength,
quality, purity, and identity and meet an acceptable in
vitro standard; 3) The drug products are bioequivalent in
that they do not present a known potential problem and
are shown to meet an appropriate bioequivalence
standard: 4) The drug products are adequately labeled;
5) The drug products are manufactured in compliance
with current good manufacturing practice (GMP)
regulations.
The generic drug product requires an abbreviated new
drug application (ANDA) for approval by the FDA and
may be marketed after patent expiration of the reference
listed drug product. The generic drug product must be a
therapeutic equivalent to the Reference drug product but
may differ in certain characteristics including shape,
scoring configuration, packaging, and excipients (includes
colors, flavors, preservatives. expiration date, and minor
aspects of labeling).
Pharmaceutical alternatives are drug products that
contain same therapeutic moiety but are different salts,
esters or complexes (e.g., tetracycline hydrochloride
versus tetracycline phosphate) or are different dosage
forms (e.g., tablet versus capsule: immediate release
dosage form versus controlled release dosage form) or
strengths.
In summary, clinical studies are useful in determining the safety and efficacy of the drug product.
Bioavailability studies are used to define the affect of
changes in the physic0 chemical properties of the drug
substance and the affect of the drug product (dosage
form) on the pharmacokinetics of the drug; whereas,
bioequivalence studies are used to compare the
bioavailability of the same drug (same salt or ester)
from various drug products. If the drug products are
bioequivalent and therapeutically equivalent, then the

clinical efficacy and safety profile of these drug

products are assumed to be similar and may be
substituted for each other.

MEASURE OF

The best measure of a drug products performance is to

give the drug product to human volunteers or patients and
then determine the in vivo bioavailability of the drug using
a pharmacokinetic or clinical study. For some well
characterized drug products and for certain drug products
where bioavailability is self-evident (e.g., sterile solutions
for injection), in vivo bioavailability studies may be
unnecessary. In these cases, the performance of the drug
product in vitro is used as a surrogate to predict the in vivo
drug bioavailability. Because these products have
predictable in vivo performance as judged by the in vitro
characterization of the drug and drug product, the FDA
may waive the requirement for performing an in vivo
bioavailability study (Table 8).

Drug Products for w ich BioavailabiIity

Drug bioavailability from a true solution is generally
considered self-evident. Thus, sterile solutions, lyophilized powders for reconstitution, opthalmic solutions do
not need bioequivalence studies but still must be
manufactured according to current GMPs. However,
highly viscous solutions may have bioavailability
problems due to slow diffusion of the active drug.

In Vitro-in Vivo orrelation ( I V I V ~ )

In vitro bioavailability data may be used to predict the
performance of a dosage provided that the dissolution
method selected is appropriate for the solid oral dosage
form and prior information has been collected showing
that the dissolution method will result in optimum drug
absorption from the drug product. In general, IVIVC is
best for well absorbed drugs for which the dissolution
rate is the rate-limiting step. Some drugs are poorly
absorbed and dissolution is not predictive of absorption
(1). The objectives of IVIVC are to use rate of
dissolution as a discriminating (i.e., sensitive to changes
in formulation or manufacturing process), as an aid in
setting dissolution specifications. When properly
applied, IVIVC may be used to facilitate the evaluation

99

Biopharmaceutics

Table 8

Examples of drug products for which in vivo bioavailability studies may be waived

Condition

Example

Comment

Drug products for which

bioavailability is self-evident

Drug solution (e.g., parented

ophthalmic, oral solutions)

Drug bioavailability from a true solution is

considered self-evident. However, highly viscous
solutions may have bioavailability problems.

In vivo-in vitro correlation

Modified release drug products

The dissolution of the drug from the drug product

in vitro must be highly correlated to the in vivo
bioavailability of the drug.

Biopharmaceutic classification
(BCS) system

Immediate release solid oral

drug products

Drug must be a highly soluble and highly

permeable substance that is in a rapidly
dissolving dosage form.

Biowaiver

Drug product containing a

lower dose strength

Drug product is in the same dosage form, but

lower strength and is proportionally similar in
its active and inactive ingredients.

(IVIVC)

of drug products with manufacturing changes including

minor changes in formulation, equipment, process,
manufacturing site, and batch size. (see section on
SUPAC) (2, 3, 10).
Three levels of IVIVC are generally recognized by
the FDA (10). Level A correlation is usually estimated
by deconvolution followed by comparison of the
fraction of drug absorbed to the fraction of drug
dissolved. A correlation of this type is the highest level
of correlation and best predictor of bioavailability from
the dosage form. A Level A correlation is generally
linear and represents a point-to-point relationship
between in vitro dissolution rate and the in vivo input
rate. The Level A correlation should predict the entire in
vivo time course from the in vitro dissolution data.
Level B correlation utilizes the principles of statistical
moment analysis, Various dissolution IVIVC methods
were discussed by Shargel and Yu in 1985, 1993, 1999
(1). The mean in vitro dissolution time is compared to
either the mean residence time or the mean in vivo
dissolution time. Level B correlation, like Level A
correlation, uses all of the in vitro and in vivo data but
is not considered to be a point-to-point correlation and
does not uniquely reflect the actual in vivo plasma level
curve, since several different in vivo plasma level-time
curves will produce similar residence times. A Level C
correlation is the weakest IVIVC and establishes a
single point relationship between a dissolution parameter
(e.g., time for 50% of drug to dissolve, or percent drug
dissolved in two hours, etc.) and a pharmacokinetic
parameter (e.g., AUC, Cmax, Tmax). Level C
correlation does not reflect the complete shape of the
plasma drug concentration-time curve of dissolution
profile.

B I O P H A ~ M A C ~ ~ TC
I CLSA ~ ~ ~ F I C A ~ I O N
SYSTEM (BCS)
The FDA may waive the requirement for performing an in
vivo bioavailability or bioequivalence study for certain
immediate release solid oral drug products that meets very
specific criteria, namely, the permeability, solubility, and
dissolution of the drug. These characteristics include the in
vitro dissolution of the drug product in various media, drug
permeability information, and assuming ideal behavior of
the drug product, drug dissolution and absorption in the GI
tract. For regulatory purpose, drugs are classified
according to BCS in accordance the solubility, permeability and dissolution characteristics of the drug (FDA
Draft Guidance for Industry, January, 1999, see FDA
website for guidance) (1 1). Based on drug solubility and
permeability, Amidon et al. (10, 12) recommended the
following BCS in 1995 (Table 9).
This classification can be used as a basis for setting in
vitro dissolution specifications and can also provide a basis
for predicting the likelihood of achieving a successful in
IVIVC. The solubility of a drug is determined by
dissolving the highest unit dose of the drug in 250 ml of
buffer adjusted between pH 1.0 and 8.0. A drug substance
is considered highly soluble when the dose/solubility
volume of solution are less than or equal to 250 ml. Highpermeability drugs are generally those with an extent of
absorption that is greater than 90%.

An objective of the BCS approach is to determine the

equilibrium solubility of a drug under approximate

Biopharmaceutics

100

Table 9

Biopharmaceutics classification system (BCS)

Condition

Comments

Solubility

A drug substance is considered highly soluble when the highest dose strength is soluble in 250 ml or less of water over
a pH range of 1-8.

Dissolution

An immediate release (IR) drug product is considered rapidly dissolving when not less than 85% of the label amount
of the drug substance dissolves within 30 min using the USP apparatus I at 100 rpm (or apparatus I1 at 50 rpm) in a
volume of 900 ml or less.'

Permeability

A drug substance is considered highly permeable when the extent of absorption in humans is to be >90% of an

administered dose based on mass balance determination.

"Media include: acidic media (e.g., 0.1 N HCI) or simulated gastric fluid, USP without enzymes, pH 4.5 buffer and pH 6.8 buffer of simulated intestinal
fluid, USP without enzymes (From FDA Draft Guidance, Jan, 1999.)

physiological conditions. For this purpose, determination

of pH-solubility profiles over a pH range of 1-8 is
suggested. Preferably eight or more pH conditions should
be evaluated. Buffers that react with the drug should not be
used. An acid 0s base titration method can also be used for
determining drug solubility. The solubility class is
determined by calculating what volume of an aqueous
media is sufficient to dissolve the highest anticipated dose
strength. A drug substance is considered highly soluble
when the highest dose strength is soluble in 250 ml or less
of aqueous media over the pH range of 1-8. The volume
estimate of 250 ml is derived from typical bioequivalence
study protocols that prescribe administration of a drug
product to fasting human volunteers with a glass (8 ounces)
of water.
Solution stability of a test drug in selected buffers (or
pH conditions) should be documented using a validated
stability-indicating assay. Data collected on both pHsolubility and pH-stability should be submitted in the
biowaiver application along with information on the
ionization characteristics, such as pKa(s), of a drug.

Table 10

ermeability Glass
Studies of the extent of absorption in humans, or
intestinal permeability methods, can be used to
determine the permeability class membership of a
drug. To be classified as highly permeable, a test drug
should have an extent of absorption >90% in humans.
Supportive information on permeability characteristics
of the drug substance should also be derived from its
physical-chemical properties (e.g., octano1:water partition coefficient).
Some methods to determine the permeability of a drug
from the GI tract include 1) in vivo intestinal perfusion
studies in humans, 2 ) in vivo or in situ intestinal perfusion
studies in animals, 3) in vitro permeation experiments
using excised human or animal intestinal tissues, and 4) in
vitro permeation experiments acsoss a monolayer of
cultured human intestinal cells. When using these
methods, the experimental permeability data should
correlate with the known extent-of-absorption data in
humans.

Postapproval change levels

Change level

Example

Comment

Level 1

Deletion or partial deletion of

an ingredient to affect the color
or flavor of the drug product

Level 1 changes are those that are unlikely to have any detectable
impact on formulation quality and performance.

Level 2

Quantitative change in excipients

greater that allowed in a Level 1 change.

Level 2 changes are those that could have a significant impact on

formulation quality and performance

Level 3

Qualitative change in excipients

Level 3 changes are those that are likely to have a significant impact
on formulation quality and performance. A Level 3 change may
require in vivo bioequivalence testing.

Biopharmaceutics

101

issolutio
The dissolution class is based on the in vitro dissolution
rate of an immediate release drug product under specified
test conditions and is intenended to indicate rapid in vivo
dissolution in relation to the average rate of gastric
emptying in humans under fasting conditions. An
immediate release drug product is considered rapidly
dissolving when not less than 85% of the label amount of
drug substance dissolves within 30 min using the USP
apparatus I at 100 rpm or apparatus 11 at 50 rpm in a
voluume of 900 ml or less in each of the following
media 1) acidic media such as 0.1 N HC1 or Simulated
Gastric Fluid USP without enzymes; 2) a pH 4.5 buffer;
and 3) a pH 6.8 buffer or Simulated Intestinal Fluid USP
without enzymes.

the FDA developed (2, 3, 5 , 3, 10, 3, 12-17) a series of

guidances for the industry that discuss scale-up and
postapproval changes, generally termed, SUPAC guidances (11). The FDA SUPAC guidances are for
manufacturers of approved drug products who want to
change 1) a component and composition of the drug
product; 2) the batch size; 3) the manufacturing site; 4) the
manufacturing process or equipment; and/or 5 ) packaging.
These guidances describe various levels of postapproval
changes according to whether the change is likely to
impact on the quality and performance of the drug product.
The level of change as classified by the FDA as to the
likelihood that a change in the drug product might affect
the quality of the product (Table 10).

FER

In addition to routine quality control tests, comparative

dissolution tests have been used to waive bioequivalence
requirements (biowaivers) for lower strengths of a dosage
form. The drug products containing the lower dose
strengths should be compositionally proportional or
qualitatively the same as the higher dose strengths and
have the same release mechanism. For biowaivers, a
dissolution profile should be generated and evaluated
using one of the methods described under Section V in this
guidance, Dissolution Profile Comparisons. Biowaivers
are generally provided for multiple strengths after
approval of a bioequivalence study performed on one
strength, using the following criteria: For multiple
strengths of IR products with linear kinetics, the
bioequivalence study may be performed at the highest
strength and waivers of in vivo studies may be granted on
lower strengths, based on an adequate dissolution test,
provided the lower strengths are proportionately similar in
composition [21 CFR 320.22(d)(2)]. Similar may also be
interpreted to mean that the different strengths of the
products are within the scope of changes permitted under
the category Components and Composition, discussed in
the SUPAC-IR guidance.

After a drug product is approved for marketing by the

FDA, the manufacturer may want to make a manufacturing change. The pharmaceutical industry, academia and

I . Shargel, L.; Yu, A.B.C. Applied Biopharrnaceutics and

Pharmacokinetics; McGraw-Hill Medical Publishing:
1999.
2. SUPAC-MR: Modified Release Solid Oral Dosage Forms;
Scale-Up and Post-Approval Changes: Chemistry, Manufacturing and Controls, In Vitro Dissolution Testing. and
In Vivo Bioequivalence Documentation, FDA, Guidance
for Industry, Sept. 1997.
3. Waiver of In Vivo Bioavailability and Bioequivalence
Studies for Immediate Release Solid Oral Dosage Forms
Containing Certain Active MoietiedActive Ingredients
Based on a Biopharmaceutics Classification System, FDA
Draft Guidance for Industry, Jan. 1999.
4. Skelly, J.P.; Shah, V.P.; Konecny, J.J.; Everett, R.L.;
McCullouen, 5 . ; Noorizadeh, A.C. Report of the Workshop
on CR Dosage Forms: Issues and Controversies. Pharmaceutical Research 1987, 4 (l),75-78.
5. Shah, V.P.; Konecny, J.J.; Everett, R.L.; McCullouen, 5 . ;
Noorizadeh, A.C.; Shah, V.P. In Vitro Dissolution Profile
of Water Insoluble Drug Dosage Forms in the Presence of
Surfactants. Pharmaceutical Research 1989, 6, 612-618.
6. Moore, J.W.; Flanner, H.H. Mathematical Comparison of
Dissolution Profiles. Pharmaceutical Technology 1996,
20 ( 6 ) , 64-74.
7. Hendeles, L.; Weinberger, M.; Milavetz, G.; Hill, M.;
Vaughan, L. Food Induced Dumping from Once-A-Day
Theophylline Product as Cause of Theophylline Toxicity.
Chest 1985, 87,758-785.
8. Allen, P.V.; Rahn, P.D.; Sarapu, A.C.; Vandewielen, A.J.
Physical Characteristics of Erythromycin Anhydrate and
Dihydrate Crystalline Solids. J. Pharm. Sci. 1978, 67,
1087 - 1093.
9. Aguiar, A.J.; Krc, J.; Kinkel, A.W.; Samyn, J.C. Effect of
Polymorphism on the Absorption of Chloramphenical
from Chloramphenical Palmitate. J. Pharm. Sci. 1967, 56,
847- 853.
10. SUPAC-IR Immediate Release Solid Oral Dosage Forms.
Scale-up and Post-Approval Changes: Chemistry, Manufacturing and Controls, In Vitro Dissolution Testing, and

Biopharmaeeutics

102

I 1.

12.

13.

14.

15.

In Vivo Bioequivalence Documentation, FDA Guidance for

Industry, Nov. 1995.
FDA Regulatory Guidances FDA Website for Kcgulatory
(iuidances. www.fda.gov/ccler/guidance/indes.htm).
Amidon, G.L.; Ixnncrnas, H.; Shah, V.P.; Crison, J.R. A
Theoretical Basis For a Biopharmaceutic Drug Classification: The Correlation of I n Vitro Drug Product
Dissolution and In Vivo Bioavailability. Pharniaceutical
Research 1995, 12, 413-420.
Skelly, J.P.; Amidon. G.L.; Barr, W.H.; Benet, L.Z.;
Carter, J.E.; Robinson, J.R.; Shah, V.P.; Yacobi, A. InVitro
and In Vivo Testing and Correlation for Oral Controlled/
Modified-Release Dosage Forms. Pharmaceutical Research
1990, 7, 975-982.
In Vitro-In Vivo Correlation for Estcnded Release Oral
Dosage Forms, Pharmacopeial Forum Stimuli Article.
United States Pharmacopeial Convention. Inc.: July 1988;
4160-4 161.
In Vitro In Vivo Evaluation of Dosage Forms, U.S.P.
XXIV< I088> United States Pharmacopeial Convention,
Inc. 2051-2056.

16. Shah, V.P.; Skelly, J.P.; Barr, W.H.: Malinowski, H.;

Amidon, G.H. Scale-up of Controlled Release Products Preliminary Considerations. Pharmaceutical Technology
1992, I6 ( 5 ) , 35-40.
17. Skelly, J.P. Rcport of Workshop on In Vitro and In Vivo
Testing and Correlation for Oral Controlled/ModifiedRelease Dosage Forms. Journal of Pharmaceutical Sciences
1990, 79 (9), 849-854.
18. Cadwallader, D.E. Biophnrmnceutics rind D rug Interactions; Raven Press: New York; 1983.
19. Cibaldi, M. Biopham~acruticsand Cinical Pharmacokinetics; Lea & Febiger: Philadelphia, 1984.
20. Cibaldi, M.; Perrier, D. Pharmacokinetirs; Marcel Dekker,
Inc.: New York, 1982.
21. McGinity, J.W.; Stavchansky, S.A.; Martin, A . Bioavailability in Tablet Technology. Pharmacrutical Dosage
Forms: Tablets; Lieberman, H.A., Lachman, L., Eds.;
Marcel Dckker, Inc.: New York, 1981; 2.
22. Rowland, M.; Tozer, T.N. Clinical Pliavmacokinelics.
Concepts and Applications; Lea & Febiger: Philadelphia,
1995.

PROFESSIONAL OKGANIZATIONS

University of Mississippi, Univer.5ity, Mississippi, U.S.A.

Council on Credentialing in Pharmacy, Washington, D.C., U.S.A.

INT

The Board of Pharmaceutical Specialties (BPS) was

established in 1976 under the auspices of the American
Pharmaceutical Association (APhA). The overriding
concern of BPS is to ensure that the public receives the
highest possible quality pharmacy services, contributing
toward outcomes that improve a patients quality of life.
The BPS has four primary responsibilities:
* To recognize specialties in pharmacy practice.
* To set standards for certification and recertification.
0
To objectively evaluate individuals seeking certification and recertification.
* To serve as a source of information and coordinating
agency for pharmacy specialties.

The BPS is located at 2215 Con\titution Avenue, NW,

Washington, D.C. 20037-2985, phone: (202) 429-7591 ;
fax: (202) 429-6304; www.bpsweb.org.

OVE~VI
Certification is a voluntary process by which a practitioners education, experience, knowledge, and skills are
confirmed by ones profession as meeting or surpassing a
standard beyond that required for licensure. The standards
and processes for certification (unlike those for licensure)
arc established by a professional, nongovernmental agency. RPS certification is at the specialty level and signifies
that an individual has met a national professional standard
and dcmonstrated mastery of a body of knowledge, skills,
and abilities in an advanced levcl in a specialized area
of practice.
Today, BPS functions as an agency of APhA with its
own governing Board structure. The board is composed

Em:).cloprdia of Clinical P Iiurmacy

DOI: 10.1OX IE-ECI 12000620I
Copyright 0 2003 by M a w 1 Dekker, Inc. All rights reserved.

of six pharmacist members, two health care practitioners

outside of pharmacy, and one public member. The chair
of each Specialty Council and the BPS Executivc Director serve as nonvoting members of the Board. The
Executive Director of BPS is Richard J. Bertin, Ph.D.,
R.Ph. and the current Chair of BPS is Rogcr W.
Anderson, R.Ph., DrPH, who is Director of Pharmacy
at M.D. Anderson Cancer Center.
To date, five specialties have been recognized by
BPS: 1) nuclear pharmacy; 2) nutrition support pharmacy; 3) oncology pharmacy; 4) pharmacotherapy; and
5) psychiatric pharmacy. As of August, 2002, 34 14 pharmacists are certified as specialists in one or morc of these
specialties. Added Qualification is a process for providing recognition of pharmacists with further training
and experience in areas of concentration within an
existing specialty.

MISSION AND OBJECTIVE

The mission of BPS was refined in 1997 and is reviewed
by the Board semiannually. The mission is to improve
public health through recognition and promotion of
specialized training, knowledge, and skills in pharmacy
and certification of pharmacist specialists. The organization achieves its mission through accomplishment of six
strategic objectives including 1) providing leadership for
the profession of pharmacy in the discussion, evolution,
direction, and recognition of specialties in pharmacy; 2)
establishing the standards for identification and recognition of specialties in consultation with the profession; 3)
establishing standards of training, knowledge, and skills
as the basis for ccrtification of individuals; 4) developing
and administering objective and valid means to evaluatc
the knowledge and skills of pharmacist specialists; 5)
evaluating areas of specialization for their value and

103

104

viability; and 6) communicating the value of specialization and specialty certification in pharmacy.

adventure\ in a treatment area where novel and expcrimental drug therapies arc lrcquently employed.

BPS has recognized five spccialty practice areas. They arc

I ) nuclear pharmacy (1978); 2) nutrition support pharmacy (1 988); 3) pharmacothcrapy (1988); 4) psychiatric
pharmacy (1992); and 5) oncology pharmacy (1 996).
Nuclear pharmacy seeks to improve and promotc public hcalth through the safe and effectivc L I S of
~ radioactive
drugs for diagnosis and therapy. A nuclear pharmacist, as
a member of the nuclear medicine team, specializes in
procurcmcnt, compounding, quality assurancc, dispensing, distribution, and developmcnt of radiopharmaceuticals. In addition, thc nuclear pharmacist monitors paticnt
outcomes and providcs information and consultation rcgarding hcalth and safety issues.
Nutrition support pharmacy addrcsscs the care of patients receiving specialized parenteral or enteral nutrition.
The nutrition support pharmacist is responsible for promoting restoration and maintenance of optimal nutritional
status and designing and modifying treatment in accordance with paticnt needs. These specialists havc rcsponsibility for direct patient care and often function as members of niultidisciplinary nutrition support teams.
Pharmacotherapy is thc specialty responsible for ensuring the safe, appropriate, and economical usc of drugs
in paticnt carc. The pharinacotherapy specialist has
responsibility for dircct patient care and often functions
as a member of a multidisciplinary treatment team. Thcsc
spccialists may conduct clinical research and arc frcqucntly primary sources of drug information for other health
care professional s.
Psychiatric pharmacy addresses the pharmaceutical
care of paticnts with psychiatric disorders. As a mcmbcr
oP a multidisciplinary treatment tcam, thc psychiatric
pharmacist specialist is often responsible for optimizing
drug treatment and paticnt care by conducting patient
asscssmcnts; rccommending appropriate treatment plans;
monitoring patient response; and preventing, identifying,
and correcting drug-relatcd problems.
Oncology pharmacy addrcsscs the pharmaceutical care
of patients with canccr. The oncology pharmacist specialist promotes optimal care of patients with various malignant diseases and their complications. These specialists
are closely involvcd in recognition, management, and
prevention of uniquc morbidities associated with cancer
and canccr trcatmcnt; recognition of the balance bctwccn
improved survival and quality of lifc as primary outcome
indicators; and provision of safeguards against drug mis-

Added Qualifications is the mechanism used by BPS to

recognize further differentiation within a specialty which
thc Board has already recognized. This distinction may be
granted to a BPS-certified specialist on the basis of a
structured portfolio rcvicw process, administered by the
Specialty Council responsiblc for the specialty. Thc first
petition for Added Qualifications was i n Infectious
Diseases and was approved by the Pharmacotherapy
Spcciaity Council and BPS in 1999. The first candidates
were conferred the Added Qualifications in Infectious
Diseases crcdcntial in 2000. A petition for Added
Qualifications in Cardiology was approved in 2000, and
the first candidates were conferred the .Added Qualifications in Cardiology Pharmacotherapy credcntial in 200 1.

When a group of interested pharmacists wishes to have a

ncw spccialty considered for recognition by the BPS, they
submit a petition to the Board. The petition is evaluated
against seven criteria: 1) need of the profession and the
public for specifically traincd practitioncrs in thc spccialty
practice area to fulfill the responsibilities of the profession
in improving the health and welfare of the public; 2) clear,
significant demand for thc spccialty by the public and
health carc system; 3) presence of a reasonable number of
pharmacist specialists practicing in and devoting significant time in the specialty area; 4) spccialicd knowledge
of pharmaceutical sciences required by thosc practicing in
the specialty arca; 5) spccializcd functions provided by
pharmacists in the specialty practice area that require
education and training beyond thc basic level attained by
licensed pharmacists; 6) education and training in the
specialty arca provided by pharmacy colleges and other
organizations; and 7) transmission of knowledge in the
specialty practice area occurring through books, journals,
symposia, professional meetings, and othcr media.
After a new specialty is recognized by BPS, a Specialty Council of contcnt cxpcrts is appointed to work
with the RPS and a professional testing firm to develop a
psychometrically sound and legally defensible certification process. Thc Spccialty Council is composed of six
pharmacists practicing in the specialty area and three
othcr pharmacists. Certification examinations consisting
of 200 multiple choice questions are administered an-

Board of ~ ~ ~ r ~ ~Specialties
c ~ u t i c ~ ~ ~

nually at designated sites throughout the United States

and in other countries. Each BPS-certified specialist must
recertify every scven years. Approved professional devclopment programs are availablc as an alternative to
sitting for a 100-item recertification cxamination in nuclear pharmacy and pharmacotherapy. BPS continually
evaluates and updates its certification and recertification
processes. Approximately every five years, a new role
delincation study is conducted for each specialty, and
cxainination specifications are modified accordingly.

Spccialty certification in pharmacy olfers numerous potential benefits of significant value to patients, other health
professionals, employers. health care systems, and the
public. Specialty certilication denotes that specialists are
highly trained and skilled and havc demonstrated the
ability to identify, resolve, and prevent drug therapy problems. They havc taken the initiative to seek additional
education and expcricnce in a spccialized pharmacy field
and exhibit a high lcvcl of comtnitmcnt to patients and thc
profession. Certified pharmacist specialists function as
valued members of treatment tcams, optimizing and individualizing drug therapy. Employers can feel assurcd
that the knowledge and skills of certified pharmacist specialists have been testcd through a rigorous, objectivc, and
peer-determined process.
Ccrtification also provides a personal reward for pharmacist specialists. Specialty certification communicates
to others that thc specialists educational and practice
accomplishments differentiate the specialist from colleagues. Many specialists feel that thcy have a competitive edge in applying for positions, and some have received reimburscment from third-party payers, because
their skills and knowledge have been validated through

105

certification. Sornc pharmacist specialists have also reported increased salaries or one-time bonuses upon attaining BPS certification.
BPS certification has been formally recognized by the
American Association of Colleges of Pharmacy, the American College of Clinical Pharmacy, the American Pharmaceutical Association, the American Socicty for Parcntcral and Entcral Nutrition, the American Society of
Health-System Pharmacists, the Ordre des Pharinaciens du
Quebec, the Society of Infcctious Discases Pharmacists,
and the Society of Hospital Pharmacists of Australia.
BPS-certificd pharmacist specialists are recognized for
thcir advanced lcvcl of knowledge, skills, and achievcment by many government agencies and health care
organizations. The following are examples of specific
benefits that may bc realized by BPS-certified pharmacist
specialists:

U.S. Nuclear Rcgulatory Commission: specialists may

be licensed as Radiation Safety Officers and/or
recognized as Authorized Users.
U.S. Department of Defense: specialists may receive
bonus pay.
U.S. Department of Veterans Affairs: specialists may
serve at higher pay steps.
U.S. Public Health Scrvicc: specialists may receive
bonus pay.
Ncw Mexico State Board of Pharmacy: specialists may
apply for specified prescribing privileges.
At least seven Colleges of Pharmacy may exempt
BPS-certified specialists from some didactic courses in
postbaccalaureate or nontraditional Pharm.D. programs. Other Colleges award advanced placement on
an individual case basis and may recognize BPS
certification in this process.
Many other national, regional, or local employers of
RPS-certified pharmacists also recognize BPS ccrtificalion in thcir hiring, salary, or privileging policies.

PHARMACY PRACTICE ISSUES

anita

la

Hcnry Ford Health Syslem, Iletroit, Michigan, U.S.A.

The utilization of a bone marrow transplantation to treat

hematologic malignancies, solid tumors, genetic disorders, metabolic diseases, immune deficicncy disorders,
and bonc marrow failures has grown tremendously since
the first successful transplant in 1968. l f these diseases
are not treated aggrcssively, they can be fatal. The scriousncss of thcsc diseases is retlected in the intense care
providcd to the patient during and after a bonc marrow
transplant. Whether the patient receives an autologous,
syngeneic, or allogcneic bone marrow transplant, thc
patient needs to be followed very closely for the first
several weeks to several ycars (depending on the type
of bone marrow transplant and type of post-transplant
complications) by the bone marrow transplant team.
After an allogcncic bone marrow transplant, the patient
needs to be seen in clinic 1 to 3 days per week for physical
examinations, blood work, special microbiology testing,
and medication adjustments. Once a bone marrow transplant patient is deemed to be stable, their outpatient visits
will slowly decrease.
The medications used during a bone marrow transplant
and post- bone marrow transplant carry extensive toxicity
profiles and have numerous drug-drug/drug-food interactions, and the majority of medications arc expensive.
These characteristics in themselves justify the necessity
of a pharmacist to bc a key member of the bone marrow
transplant team.

Thc majority o f bone marrow transplant centers (espccially thosc pcrforming allogeneic bone marrow transplants) in the United Statcs have a pharmacist on the
team. Currently, there arc approximately 450 bone marrow transplant centers registered in 48 different countries
with thc National Marrow Donor Program."' In most
cases, thc pharmacist is employed by the Department of
Pharmacy with partial or completc financial support from
the Department of Medicine. With thc stringent criteria
106

developed for medical reimbursement by third-party

payers (i .e., health maintenance organizations, preferred
provider organizations, and mcdicaid/medicare), both the
Departments of Pharmacy and Medicine have a strong
interest in driving cost down. Since 11-37% of a bone
marrow transplant cost is attributed to pharmaceuticals,
the pharmacist plays a critical rolc in lowering the cost of
a bone marrow transplant via close medication monitoring.12' Similar to other clinical pharmacists, the bone
marrow transplant pharmacist needs to monitor all drugs
given to the patient Ior appropriate usage. However, the
majority of medications used by a bone marrow transplant
patient carry high levels of toxicities, narrow therapeutic
windows, and life-threatening results if mcdication doses
are forgotten or increased or decreased by thc patient,
thereby elevating the intensity of drug monitoring.
The bone marrow transplant team members primarily
consists of a specially trained hematologist/oncologist,
pharmacist, nurse practitioner/physician assistant, social
worker, dietitian and/or total parenteral nutrition (TPN)
personnel, and ? hematology/oncology medical fellow(s).
The team members rely heavily on each other to ensure
that appropriate, safe, and cost-effective care is given to
each patient. The pharmacist-nurse practitioncdphysistant relationship assists in combining physical
assessment findings with drug outcomes. The pharmacist-social worker relationship is necessary for discharge
planning to ensure medication affordability and appropriate home medication administration. The pharmacistdietitian/TPN personnel rclationship helps decrease
drug-food interactions with mealtime plan changes
and/or meal content changes and decrease cost by minimizing intravenous hyperalimentation usage. In some
institutions, the pharmacist plays a lead role in dietary
care, thereby negating the need for an additional dietary
personnel. The pharmacist~hematology/oncoIogy fellow relationship is primarily a teaching role for both
parties. Finally, a sound pharmacist-physician relationship needs to be developed for the physicians to entrust
patient care to a pharmacist. Once this bond has been
established, a pharmacist's knowledge can be used for
clinical advice on patient care, investigating innovative

Enc.yc.lope.din qr ('1inic.d Phnrrnucy

DOI: 10.108 l/E-ECP 120006224
Copyright 0 2003 by Marcel Dekker, Inc. All rights rescrved.

Bone Marrow Transplant Pharmacy Practice

options for patient care, and developing research protocols to advance patient care. Therefore, in addition to a
solid knowledge base in hematology-oncology, immunology, infectious diseases, fluid/electrolyte balance, and
pain management, it is imperative for a bone marrow
transplant pharmacist to possess excellent communication
and people skills.

107

Because the patients immune system is compromised

for several months to several years secondary to the slow
process of complete bone marrow recovery and/or longterm usage of immunosuppresives, the patient is vulnerable to numerous life-threatening infectious disease
processes. In addition, the allogeneic bone marrow transplant patient always carries a certain risk (highest per-

Table 1 Pharmacists responsibilities

Unstable patient

Stable patient

Adjust medication regimen(s) based on drug levels to

enhance efficacy and/or prevent toxicity.b

Adjust medication regimen(s) based on drug levels to

enhance efficacy and/or prevent toxicity.a.b

Monitor diug-drug and drug-food interactions to

prevent toxicity.

Monitor drug-drug and drug-food interactions to

prevent toxicity.

Educate the bone marrow transplant team about each

medications effect on the bone marrow.d

Educate the bone marrow transplant team about each

medications effect on the bone marrow.asd

Offer advice on antibiotic choice(s) based on microbiology

results, patients immunologic state (i.e., neutropenic,
type of underlying cancer), patients infectious disease history
(i.e., past infection(s), serology results), institutions
microorganism-drug susceptibility record, and institutions
microorganism resistance pattern.
Adjust fluids and electrolytes based on daily laboratory values
and medication changes.e
Pain management. Acute pain secondary to mucositis needs
persistent close monitoring and abrupt drug adjustments to
attain near complete pain control within 4-6 hours.

Pain management. Chronic pain secondary to chronic

GVHD needs close monitoring and drug adjustments to
attain near complete pain control within 24-48 hours.

Monitor patients for acute toxicities secondary to conditioning

regimen 2 immunosuppressive agents. In addition, offer advice on
preventive therapies for toxicities and treatment options for toxicities.

Monitor patients for chronic toxicities secondary to

conditioning regimen *immunosuppressive agents. In
addition, offer advice on preventive therapies for
toxicities and treatment options for toxicities.

Educate patient upon discharge on the importance of each

medication by clearly writing the brand name and generic name
of each medication, explaining the purpose of each medication,
the time(s) of day each medication should be self-administered, the
consequences of missing or doubling doses, and a contact name
(preferably the pharmacist) and phone number for use if further
questions arise at home.

Assure medication compliance by reviewing medication

calendar. Once the patients are stable, they are more apt
to develop their own regimens. These regimens may allow
medications to be dosed too close together or too close to
meal times, skip certain medications deemed unnecessary
by the patient, and/or add certain medications (i.e., natural
herbs, vitamins).

Conduct clinical research. Pharmacist-initiated research projects

arise frequently from day-to-day unresolvable issues. Pharmaceutical
industry-sponsored research projects are also available.f

Conduct outcome-based research. Because a pharmacist

closely monitors the bone marrow transplant patients
for a prolonged period of time, there is an abundance of
data available for outcome-based research.

aExamples include, cyclosporine, tacrolimus, aminoglycosides, vancomycin.

bThese tasks are performed at a lower intensity level than their counterparts.
Examples include, choice of antihypertensive agent to be used while on cyclosporine or tacrolimus, timing medication ingestion around meal times.
dAfter identifying medications that are detrimental to the bone marrow, offer options for treatment that have no effect or minimal effect on the bone
marrow.
eThe pharmacist has the key role in preventing fluid and electrolyte abnormalities from occurring secondary to medications and aggressively correcting
all fluid and electrolyte abnormalities.
Pharmacists need to be aggressive in indentifying projects and seek funding for the project^.'^' Pharmacists should strive to be the primary investigator or
coinvestigator on the projects.

108

centage if the donated bone marrow is from an unrelated individual without a 6/6 Human Lymphocyte
Antigen match) for developing acute and/or chronic
graft-versus-host disease (GVHD). If the patient develops GVHD, the immune system is even further compromised by not only the intense immunosuppressive
agents needed for treatment, but also by the GVHD
itself. Thus, an allogeneic bone marrow transplant patient may have numerous hospital readmissions for
treatment of infectious disease processes, aggressive
treatment, and close monitoring of moderate-to-severe
GVHD or bone marrow failure (i.e., tumor relapse, bone
marrow engraftment lost). The majority of patients are
at highest risk for readmission during the first 100 days
post-transplant. Bone marrow transplant recipients of
mismatched or unrelated donors require more intense
bone marrow immunosuppression for a longer period of
time than their counterparts who receive matched or
related bone marrow, thereby increasing their risk for
hospital readmissions for a period greater than 100 days.
Because the patients medical needs can change drastically from day to day, the pharmacist needs to stay
abreast of all new medication regimens required for
patient care. It is imperative that the pharmacist has a
good working relationship with the patient and patients
caregivers to ensure appropriate adherence to the evolving medication regimen.
Recently, there has been a surge of bone marrow
transplant centers shifting inpatient care to the outpatient
setting early in transplant (post bone marrow/peripheral
blood stem cell infusion). The incentive for this trend has
been to decrease the cost of bone marrow transplant and
improve the patients quality of life. Stringent, institutionspecific criteria have been developed for patients to be
outpatient bone marrow transplant candidates. The primary basis behind the criteria rely on the patient and a
dedicated caregiver to be attentive to all their medical
needs, including comprehension of appropriate medication administration guidelines. The patients are responsible for self-administration of scheduled and as needed
oral, subcutaneous, and intravenous medications. By
placing this level of responsibility on the patient and
caregiver, the patient can be overcome with anxiety. A
pharmacist plays a dominant role in alleviating any confusion or misunderstanding on medication self-administration. The bone marrow transplant pharmacist will
need to thoroughly educate both the patient and caregiver
on all the medications daily. Although the patient maybe
medically stable in the outpatient setting, the initial
amount of time the pharmacist needs to spend with the
patient is equivalent to a complicated hospitalized bone
marrow transplant patient.

Bone Marrow Transplant Pharmacy Practice

There is a definite need for both an inpatient and

outpatient bone marrow transplant pharmacist. Due to the
patients initial prolonged inpatient stay and high probability of multiple readmissions during the first several
months post-bone marrow transplant, the distinction between an inpatient and outpatient bone marrow transplant
pharmacist role becomes unclear. To help maintain continuity of care, usually one pharmacist (labeled as the
inpatient pharmacist) will manage a patients pharmaceutical needs both during the initial hospitalization and
during the first several months of outpatient care. Once a
patients ambulatory visits decrease to at least once every
2 weeks, the outpatient pharmacist will attend to the
patients medication needs. If the institution predominantly performs autologous bone marrow transplants or if
the number of bone marrow transplants (autologous
combined with allogeneic) performed is low, then one
pharmacist is sufficient to play both the inpatient and
outpatient role.
The type and level of care provided by the pharmacist
depends on the stability of the patients health (Table 1).
Generally, the patient is most unstable during the
transplant and for the first several months post-transplant.

The type of work a bone marrow transplant pharmacist

performs on a daily basis depends on the goal of the
employer. A pharmacist can be predominantly research
based or clinically based.

Most of the bone marrow transplant pharmacist positions

with research emphasis are tenure-tracked or tenured with
a teaching hospital. These pharmacists have minimal to
no direct patient care duties assigned to them. Pharmacists
are responsible for the following:

1. Developing research protocols

2. Applying for grants to fund the protocols
3. Screening and enrolling patients into study (when
applicable)
4. Developing/running various assays
5 . Publishing research results
6. Didactic, experiential university-based teaching
The majority of pharmacists will participate in
pharmacy doctoral or postdoctoral programs or develop
bone marrow transplant fellowships to attain reliable,

109

Bone Marrow Transplant Pharmacy Practice

hardworking assistance in the laboratory. In turn, the

students/fellows will be closely mentored by the pharmacist. This symbiotic relationship will allow both parties
to augment research productivity, increase the number
of publications, and attain larger funding sources.

Most of the bone marrow transplant pharmacist positions with clinical emphasis are nontenure-tracked.
The pharmacists primary job responsibilities revolve
around direct patient care. Pharmacists are responsible
for the following:

1. Reviewing patients laboratory bloodwork, microbiology results, and medication profiles on a

daily basis
2. Attending and actively participating in patient medical rounds and patient clinic visits
3. Reviewing medications used in bone marrow transplant patients for inpatient and outpatient formulary usage
4. Helping to standardize care by developing protocols and procedures for bone marrow transplant
medication utilization
5 . Publishing material related to bone marrow transplant patient care
Although a clinical pharmacists emphasis is on direct
patient care, many of the pharmacists do perform clinical
research, seek for grants or awards to fund their research
projects, publish research results, participate in university-based teaching (didactic k experiential), and assist in
mentoring pharmacy residents specializing in hematology-oncology. A clinical pharmacist is expected to remain abreast of the bone marrow transplant literature,
especially in the following areas: GVHD, veno-occlusive
disease, infectious disease processes, and chemotherapyradiation-related toxicities. In addition to the pharmacists clinical knowledge, the bone marrow transplant
team heavily relies on the pharmacist for their knowledge
of the practical aspects of pharmacy (i.e., compatibility
issues, ability to compound products, maximudminimum concentrations of intravenous medications, understanding of the institutions medication order entry and
medication delivery processes). The clinical bone marrow transplant pharmacists main goals are to provide
safe, therapeutic, and cost-effective care to each patient,
and to maintain continuity of patient care upon initial
hospital discharge.

HEALTH OUTCOME AND

Currently, there is no published literature documenting

health outcome or economic benefits provided by a
pharmacist to a bone marrow transplant patient. There are
several review articles analyzing the economics of bone
marrow transplant, peripheral blood stem cell transplant,
and outpatient-based tran~plant.[~.~-l
The articles refer to
various detailed cost-effective and cost-minimization
studies. Unfortunately, they do not breakdown the cost
analysis studies to note the impact a pharmacist has on the
total cost of a bone marrow transplant procedure. The
input provided by a pharmacist to the bone marrow
transplant team is substantial and necessary for a cancer
center to remain competitive and fiscally responsible.
There is a strong need for bone marrow transplant
pharmacists to generate outcome data and collectively or
individually publish the benefits of retaining a pharmacist
on the bone marrow transplant team.

NECESSARY TOOLWMATERIALS
Medline
Many of the complications encountered during a bone
marrow transplant have few (if any) standardized
treatment protocols developed. Therefore, pharmacists
need easy accessibility to a medline service during and
after patient rounds to provide valuable information to the
bone marrow transplant team in a timely manner. Although physicians may also perform their own research
on the topic of discussion, it is important for pharmacists
to critique and review the literature separately. This will
allow the pharmacist to

1. Evaluate various innovative treatment options.

2. Choose the best option that complies with the
hospital policies and procedures for drug attainment, drug compounding, and drug administration.
3. Resolve drug availablity issues (i.e., orphan drug
status, length of time to receive drug in hospital).
4. Present the options to the bone marrow transplant
physician in a timely manner.

Hematopoiesis Chart
The bone marrow transplant pharmacist needs to have a
sound understanding of the maturation of the hemato-

I10

Bone Marrow Transplant

poictic stem cell to form the three lineages. It is important to understand the rclevancc of immunomodulators
at each step of cell maturation. ecausc ex-vivo cytokines are very expensive and many of them carry high
toxicity profiles, it is important for a pharmacist to
know which stem cell maturation step(s) will be influcnccd by the cytokine(s).

Currently, there are no published documents providing

guidelines or consensus statements on how medications
should be administered during and following a bone
marrow transplant. There are numerous review articles
available on bone marrow transplant preparative regimens, prevention and treatment of graft versus host
disease, infectious disease topics related to bonc marrow transplant, and pain management. The chemothcrapy/radiothcrapy used as the preparative regimen for a
bone marrow transplant varies from center to center,
depending on the hematologists past experience with
thc various regimens, the patients eligibility for drug
study enrollment, the patients past chemotherapy/radiotherapy history, and the patients past medical history.
Thc medications and medication doses used to prevent
D and to treat other bone marrow transplant related complications is also dependent on the physicians preference, patients cligibility for drug study
enrollment, and patients medical history.

Ilnfortunately, a pharmacy conference/meeting specializing or subspecializing in bone marrow transplant

has not been identified. There is a rising interest in
forming a bone marrow transplant pharmacy network
group; perhaps modclcd after the infectious disease
pharmacy group (Society of Infectious Disease Pharmacy meet annually at their medical counterpart conference, Interscience Conference on Antimicrobial Agents
and Chemotherapy).
ACCP Oncology pm mainly targets the hematology/
oncology pharmacists and ACCP Transplant prn mainly
largets the solid organ transplant pharmacists. Thus,
bone marrow transplant pharmacist members of ACGP
arc not strongly committed to any particular ACCP
pm group.

I.

2.

3.

4.

5.

Thcrc are numerous bone marrow transplant web sites

available; however, they arc oncology center initiated to
increase patient relerral base or patient initiated to provide personal advice to other bone marrow transplant
patients. The networking opportunities available for bone
marrow transplant pharmacists are primarily in the following medical conferences/mcctings:

I . American Society of Hematology (ASH)

2. American Society of Clinical Oncology (ASCO)

6.

I.

http:/IIBMTK.org/sitemap/sitcmap/html
(acccsscd Scptcmber, 2000).
Bailey, E.M.; Pindolia, V.K. How to obtain funding for
clinical research. Am. J. Hosp. Pharm. 1994, 51, 2858~2860.
Weeks, F.M.; Yee, G.C.; Bartfield, A.A.; Wingard, J.R.
The true cost of bone marrow transplantation. Am. J. Med.
97, 314 (2), 101 112.
Waters, T.M.; Bcnnctt, C.L.; Pajeau, T.S.; Sobocinski,
K.A.; Klein, J.P.; Rowlings, PA.; Horowitx, M.M. Economic analyses of bone marrow and blood stem cell
transplantation for leukemias and lymphoma: What do we
know? Bone Marrow Transplant. 1998, 21, 641 650.
Bennett, C.L.; Waters, T.M.; Stinson, T.J.; Almagor, 0.;
Pavletic, Z.S.; Tarantolo, S.K.; Bishop, M.R. Valuing
clinical stratcgics early in development: A cost analyses of
allogeneic periphcral blood stem cell transplanlation. Bone
Marrow Transplant. 1999, 24, 555-560.
Rixzo, J.D.; Vogelsang, G.B.; Krumm, S.; Frink, B.; Mock,
V.; Bass, E.B. Outpatient-based bone marrow transplantation for hematologic malignancies: Cost savings or cost
shifting? J. Clin. Oncol. 1999; 17 (9), 281 1 2818.
Barr, K.; Furlong, W.; Henwood, J.; Feeny, D.; Wegener,
J.; Walker, 1.;Brain, M. Economic evaluation of allogeneic
hone marrow transplantation: A rudimentary model to
generate estimates for the tinicly formulation o f clinical
policy. J. Clin. Oncol. 1996, 14, 1413 - 1440.

PROFESSIONAL ORGANIZATIONS

aton
Univenity of Toronto, Toronlo, Onhrio, Canadi

I
The mission of the Canadian Hospital Pharmacy Residency Board is to establish and apply standards for
accreditation of pharmacy practice residency programs
and to promote excellence in hospital pharmacy residcncy
programs and practice. The key objectives are as follows:

1
2

To gain cxternal recognition dnd support tor phdrmacy residency program\

To provide \upport to residency program participants i n their role through educdtion, skill development and practice tools
To foster an environment that facilitates the growth
and development of ph'irmacy reiidency progrdinc

The Canadian Hospital Pharmacy Rcsidency Board was

established in the early 1960s. The assessmcnt of the residency training programs was done following review of
written documentation submitted to the Board. The onsite accreditation process and survcy did not begin until
the early 19XOs, however. At the present time, the Board
accredits residency training programs in pharmacy
practice. Currently, there are 30 programs in Canada
with 104 positions for prospective rcsidents. The Board is
not currently involvcd in thc accrcditation of specialty
programs or pharmacy technician training programs.

The current major initiatives consist o f

The Canadian Hospital Pharmacy Kesidency Board is organized under the auspices of Canadian Society of Hospital Pharmacists. The Board consists of seven members.
The terms of reference of the Board specifics that at least
one of the members be from a recognized Faculty of
Pharmacy. The membcrs of the Board are selected by the
Board itself and approved by CSHP Council. A chairperson and vice-chair are elected from the seven member
Board, with a term of two years for each of the executives.
The members themselves serve for two years, a term
which is renewable twice for a total of six ycars.
The Canadian Hospital Pharmacy Residency Board
currently conducts its work under thc auspices of the
Canadian Society of Hospital Pharmacists. As such, the
Board is provided administrative support from CSHP (at
1145 Hunt Club Road, Suite 350, Ottawa, Ontario, KIB
0V3; telephone 61 3-736-9733).

Enryrloprdia ($ Cliiiical Phcinnary

DOI: lO.IOXl/E-ECP120006286
Copyright C 2003 by Marcel Dekkcr, Inc. All rights reserved

I . Consistent with the four-year cycle for accreditation, to updatc the standards of the Board for 2002.
2. To promote thc use of the CHPRB-sponsored preceptor guidelines.
3. To evaluate the nccd or innovative specialty
practice standards and, in particular, those to be
used in an ambulatory setting.
4. To conduct a needs assessmcnt of residents who
havc becn in the residency training program over
the past threc years to determine future directions
of residency training in Canada.

w w w .cshp .ca

111

PROFESS I 0 NA L 0 RGAN IZATIO NS

sto
Canadian Pharmacists Association, Ottawa, Ontario, Canada

The Canadian Pharmaceutical Association (CPhA) was

founded in September 1907 as a national body for the
profession of pharmacy in Canada. Its involvement in
publishing began early in its history with the assumption
of responsibility for the Canadian Formulary in 1929.
The first edition of the Compendium of Pharmaceuticuls
and Speciulties (CPS) was published in 1960 and continues today, along with a number of other well-respected health care publications including Nonprescription
Drug Kejerence ,for Health Projessionals, Compendium
of Nonprescription Products, Therapeutic Choices, and
Herbs: Everyduy Rejerence ,for Health Professionals.
The latter is published jointly with the Canadian Medical Association.
Throughout the late 1980s and early 1990s, CPhA scope
of activities increased with staffing in the areas of professional development, research, and government and
public affairs.
In 1995, CPhA began to change its structure from an
organization representing provincial and national pharmacy organizations to an organization representing individual pharmacist members. This was followed in 1997
by a name change from Canadian Pharmaceutical Association to Canadian Pharmacists Association to better reflect the associations mandate.

of president, president-elect, past president, and three

vice presidents.
The executive dircctor, who is a nonvoting member
of the Executive Committee and Board, is responsible
for the management and control of the affairs of the
Association and general direction established by Board
policy. A staff o approximately 50 reports to the cxccutive dircctor.

The Canadian Pharmacists Association is the national

voluntary organization of pharmacists committcd to providing leadership for the profession of pharmacy.
The vision of CPhA is to establish the pharmacist as
the health care professional whose practice, based on
unique knowledge and skills, cnsurcs optimal patient outcomes. CPhA will achieve its vision by serving its members through:
Advocacy.
* Facilitation.
* Provision of knowledge.
0
Participation in partnerships.
0
Research and innovation.
Education.
0
Health promotion.
0

trate

CPhA is an organization of approximately 9000 individual members. Members directly elect members of the
Board or Directors to represent each province, pharmacy students, and thc three practice specialties of hospital pharmacy, industrial pharmacy, and academia. The
Board is responsible for managing the affairs of CPhA.
The Board clccts an Executive Committee comprised
112

CPhA operates according to its strategic plan developed

in 1999 and revised in 2001. The plan has five key result
areas:
1. To represent the interests of a majority of pharmacists and to create cohesiveness within the
profession on matters of practice, principle, and
policy.
Encyclopedia of Clinical Pharmacy
DOI: 10.1081iE-ECP120006202
Copyright 0 2003 by Marcel Dekker, Inc. All rights reserved.

113

Canadian Pharmacists Association/Association des Pharmaciens du Canada

2. To promote and facilitate the evolution of the

pharmacy profession toward an expanded role in
health care.
3. To foster public recognition of pharmacists as drug
experts and as members of the health care team.
4. To secure appropriate reimbursement for pharmacists professional services.
5 . To effectively analyze and respond to the impact
of advances in information technology on pharmacy practice.
6. To align resources to the key result areas.

CPhA has taken the leadership position in addressing

the shortage problem in the profession by initiating the
development of a proposal for a labor market study to
help pharmacy understand the current manpower
shortage and its causes and develop tools to forecast
future needs. Human Resources Development Canada
(HRDC) commissioned an initial phase of the study,
which is a literature search and key informant interviews to identify gaps in the available data. This
study, A Situational Analysis of Human Resource
Issues in the Pharmacy Profession in Canada, is available on the CPhA web site.] The next step is development of a proposal for funding from HRDC for a
comprehensive human resources study of the pharmacy
profession in Canada to develop the foundation required to properly manage current and future pharmacy
human resources.

Prescri

tho r ity

One of the key objectives of the strategic plan is a

move to acquire prescribing authority for pharmacists.
CPhA has developed a discussion paper to foster debate within the profession. The document has been
distributed to solicit pharmacists and other stakeholders input.

Privac

care until January 2002. With the passage of the

legislation, CPhA participated in a working group with
six national health provider and consumer associations
to examine the issue of privacy protection in Canada.
The report of the Privacy Working Group focuses on
the challenges of developing and implementing principles for privacy protection. lt highlights the lack of
consensus and the tension on this issue due to the disparate perspectives of the many stakeholders involved.
CPhA continues to seek effective remedies to the shorcomings in the legislation, including presentations to
federal officials.

It is recognized that pharmacists are spending an excessive amount of time dealing with claims reimbursement
with third-party payers. This is having a significant impact on working conditions, and administrative burdens
are proving an impediment to patient care. As a result,
CPhA joined forced with the Canadian Association of
Chain Drug Stores and the Ontario Pharmacists Association to sponsor a 2-day workshop to tackle these issues.
Priorities for action include a standardized drug benefit
card and PIN lists, patient awareness, benefit plan messages, and further collaboration with insurers and pharmacy software vendors.

har
tan
tan
Over the last decade, CPhA has been a leader in the
development of pharmacy communication standards.
CPhAs PECS Version 3.0 facilitates more than 98%
of the electronic pharmacy claims in Canada. PECS
Version 3.0 has undergone extensive revisions and now
is being integrated into a National E-Claims Standard
lnitiative (NeCST)[31 designed to address the current
need for a national electronic standard for health
claims information.

i~lation

CPhA was pivotal in securing an amendment to the

Personal Information Protection and Electronic Documents ActL2] which delayed its application to health

A major reengineering of the CPhA web site is underway.

This revitalized site will offer Web services to benefit our
members (e.g., electronic membership and order transactions, chat rooms, e-mentoring, e-broadcast).

I I4

Canadian Pharmacists AssociationlAssociation des Pharmaciens d~ Canada

In association with this initiative, an e-commerce advisory committee advises on e-commerce strategy and
assists with visualizing and developing enhancements to
CPhAs web site for member and nonmember pharmacists, other health care professionals, and consumers.

CPhAs annual meetings generally are held in May of

each year in major locations in Canada.

EF
CPhA, through its publishing program, provides pharmacists in every practice setting with accurate, current drug
information and resource materials. However, on-line
of our drug information presents new challcngc. Work is underway on the CPS so that this publication can be easily accessible Tor print and electronic
publishing. The CIS and our other publications are being
rcpurposed for use on new e-media platforms.

I.

ES

A Situational Analysis of Human Resource Issues i n the

Pharmacy Profession in Canada. http://www.cdnpharm.ca

(accessed Junc 25, 2001).

Personal Information Protection and Electronic Documents Act. http://www.privcom.gc.ca (accessed June 22,
2001).
3. National e-Claims Standard Initiative. http://www.cihi.ca/
eclaims/intro.shtml (accessed June 25, 200 I ).
2.

PROFESSIONAL DEVELOPMENT

University o f Mdryhnd, HJltiinore, Maryland, U.S.A.

INTR
Drug therapy plays a critical role in cmergency medical
care and, as a result, places the pharmacist in a position to
have a significant impact on potcntially life-saving thcrapeutic maneuvers. Pharmacists who practice in emcrgency medical carc scttings are oftcn called upon to
providc drug-related services and information without the
luxury of time to retrieve information from external
sources. This article reviews the role of pharmacy services i n both the cardiac arrest setting and in the provision of other crnergency medical scrvices in which
pharmacists play a central role.

pitals has been collected through questionnaires or surveys. Activities most frequently reported by pharmacists through such surveys are drug preparation, dosage
and infusion rate calculation, drug use documentation,
and thc provision of drug information; very few pharmacists administer artificial respiration or chest compression.12 Less frequently reported activities iiiclude
setting up or operating infusion dcvices and administering medications.
According to data from the National Clinical Pharmacy Services study from 1992 to 1998, approximately
30% of 950- 1600 hospitals surveyed had a pharmacist
as an active member of the team attending most
cardiac arrcsts when the CPR team pharmacist was in
the hospital.
Dcspite the significant percentage of
hospitals in which pharmacists arc members of the
cardiac arrest team, only 0.2%-0..3%1 of inpatients who
experienced a cardiac arrest receivcd resuscitation by a
team that included a pharmacist. This disparity may be
due to the fact that a CPR team pharmacist is not providing 24-hour, 7-day-per-week coverage, or that the
CPR team pharmacist was assigned to providc scrvice
only in a specific area of the hospital. The national
study also rcvealed that, of the hospitals with a pharmacist on the CPR team, approximately 65% routinely
document pharmacists involvement in patients medical
records. The average time cornmitinent for pharmacists
per arrest was 35 minutes. In the 1992 survey, this
amount of time per encounter was more than the avcrage amount of time for any other clinical scrvice
examined in the survey.
There is limited documentation of the value of pharmacists on cardiac arrest teams. What little data there are
tend to be anecdotal in nature. As far back as 1972, Elenbaas responded to a review of thc value of organized
cardiac arrest teams in hospitals by noting the obvious
absence of the inclusion of a pharmacist as a member of
the team.61 Given the extremely small number of actual
patient arrests in which pharmacists participate, it would
be difficult to accurately measure the actual or perceived
value of pharmacist participation. Based on the small

The spectrum of carc required for patients in cardiac

arrest ranges from providing basic life support (Cardiopulmonary resuscitation, or CPR) within or outside of
an organized health care setting, to evaluating and trcating complex cardiac arrhythmias in patients with multiple comorbidities receiving advanced cardiac life suphave bcen involved in the development
of drug-rclated health services designed to support the
care of such patients since the late 1960s. As scientific
and clinical outcome data has dramatically expanded
since thc 1960s and the efficacy of drug use in the cardiac arrest setting has been more critically evaluated,
potential roles for thc pharmacist have become more
obvious. In addition, as hospital accrediting agencies begin to address quality improvement issues in the cardiac
arrest setting, the evaluation and documentation of rational drug use will become a [actor in setting standards
of care.

ENT

AClST

The majority of information related to the activities of

pharmacists participating in cardiac arrest teams in hos-

Erryclopedia of Cliniwl Pliarnzucy

DOI: 10.108 I/E-ECP 120006320
Copyright C 2003 by Marccl Dckkcr, Inc. All rights rescrved

115

116

number of reports in the litcrature, the provision of drug

information seems to evoke the most comincnts rcgarding the value of pharmacist participation. Because the
role of physicians and nurses in the cardiac arrest setting has been so well establishcd compared with the role
that pharmacists currently fill and becausc thcrc arc
currently no standards established for pharmacists activities in this setting, the valuc of the pharmacist remains to
be measured.
A well-delineatcd support role for the pharmacist in thc
provision of care in the cardiac arrest setting clearly
exists. The pharmacy department in concert with the
hospital Pharmacy and Therapeutics Committee has a
defined and traditional role in maintenance of the
crnergcncy drug boxes (crash carts) located in various
parts of the hospital. Assuring that emergency drug boxcs
are appropriately stocked and meet the nccds of the
institution, a s mandatcd by the Pharmacy and Therapcutics Committee or other medicaf ovcrsight committee has
been a well-established support role for pharmacy
services for many ycars. As Advanced Cardiac Lifc
Support (ACLS) guidclines periodically changc and new
information related to pharmacothcrapcutic efficacy of
new and older drugs used in the cardiac arrest setting
becomes availablc, thc role of the pharmacist in updating
thc contcnts of the emergency drug box is critical to
maintaining the standard of care for drug delivery in the
cardiac arrest setting.
In addition to thcir role in drug delivery, thc pharmacists role of educator in the appropriatc use of drug
therapy in the cardiac arrest patient has been established
in a number of hospitals across the United States. This
educational role is important for several rcasons. First.
because cardiac arrests occur infrcyucntly, cspccjally in
noncritical care areas of the hospital, thc medical and
nursing staff may not be as familiar with either the
pharmacotherapeutic guidelines established by ACLS
rccomniendations or the appropriate administration tcchniques for AC1.S drug a s are providers in critical care
areas. Second, even in critical care units, implementing
change in longstanding ACLS drug administration bchaviors (modifying the role of lidocaine or sodium bicarbonate use) is often resisted by clinicians, but it is
often csscntial to the provision of quality care. Third,
dcspitc the fact that changes in the official ACLS drug
therapy guidelines occur only cvcry 5-6 ycars, the results
of landinark clinical trials often dictate changes in therapy
prior to thcir incorporation into published guidclincs.
in many hospitals have takcn active roles in
teaching physicians, nurses, and affiliated health professionals the pharmacology and therapeutics of drugs used
in the ACLS guidelines.

Cardiac A ~ ~ e s ~ ~ m Pharmacy
e r ~ ~ nServices
c ~

The education and training nceds of pharmacists who

scrve as members of the cardiac arrest team vary from
those that may be provided in some schools of phannacy.
All health care providcrs, as well as most laypcrsons,
should be certified in Basic Life Support (BIS). In a study
using questionnaires to determine attitudes toward and
use of cardiopulmonary resuscitation training received in
a school or pharmacy, 72% of responding graduates survcycd bclieved that a CPK-KLS program should be mandatory for graduation. Seventy percent of respondents
believed that thcir training would be o f value in their
current practice, and 93% believed that such training
would be of value in the future, dcspitc thc fact that only
5% had actually performed CPK since graduati~n.~
Clearly, pharmacist members of a cardiac arrest tcam
should possess BLS skills. In addition, since automatcd
extcrnal defibrillators have been dernonstratcd to improve
the chances of out-of-hospital cardiac arrest, training in
the use of thcsc devices is becoming an inherent part of
BLS training both within hospitals and in routine BLS
out-of-hospital training.x,In addition to the prerequisite
BLS training, cardiac arrest team pharmacist should be
certified in ACI.S, [he procedure in which most drug
therapy is instituted in the cardiac arrest setting. Even if
the role of the pharmacist a s a team member is limited to
drug preparation or documcntation, it is csscntial that the
pharmacist understand the rationale, efficacy, and potential sidc cffccts associated with the use of the drug therapy
bcing implemented. As in all other clinical pharmacy
practices, thc cardiac arrest team pharmacist should be
trained to monitor for both the efficacy and side effects of
the agents being used.
The need for the cardiac arrest team pharmacist to be
certified in ACLS is further rcinforced by the standards
developed by the Joint Commission on Accredivation of
Health Care Organizations (JCAHO) related to in hospital
cardiac arrests. O Of the several standards adopted by the
commission, several relate to activities in which the
pharmacist may have a significant role. These standards
includc the development of appropriate policies, procedures, proccsses or protocols governing the provision of
resuscitative services, appropriate data collection related
to thc process and outcomes of resuscitation, and ongoing review of outcomes, in the aggregate, to identify
opportunities for improvement of resuscitative efforts.
According to the Bethesda Conlerence on Cardiopulmonary Rcsuscitation, the majority of U.S. hospitals are dcficicnt in one or more of the areas in which thcsc new
JCAWO standards have been cstablished and will requirc
significant restructuring of thcir resuscitative efforts. I It

Cardiac ArresUEmergency Pharmacy Services

is clear that a real opportunity exists for the pharmacist to

influence those efforts related both to the improvement of
drug use policies, and to the creation of quality improvement and feedback processes that can identify and
improve hospital resuscitative efforts. Despite the assumption that hospitals function as self-contained emergency medical services (EMS) systems with respect to
their management of cardiac arrest based on their
abundance of health care providers in a defined environment, the Bethesda Conference report stated, "the process
of improving resuscitation in the hospital remains in its
infancy." Such an assessment presents a unique opportunity for pharmacy to establish itself as a necessary
component of a process that has become a part of required
standards of hospital care.

MERGENCY MEDICAL SERVl

Pharmacists have provided clinical services in emergency
medicine-related areas of hospitals since the late
1960s."*] Documentation of clinical pharmacy services
relate primarily to the provision of services in hospital
emergency departments. Services vary from those provided fundamentally as support to the emergency department staff, to those provided directly to patients in
specific disease management program^."^ 14' In a report
of follow-up observations on 3787 pharmacotherapy consultations provided in an emergency department in a university hospital, 33% involved patients with pulmonary
disease, 22% involved toxicology cases, 17% involved
patients with seizure disorders. 11% involved cardiac
cases, 7% were pharmacokinetic consultations, and 8%
were miscellaneous consultations."'] Consultations averaged 100 minutes each, and serum drug concentration
determinations primarily involved theophylline, phenytoin, phenobarbital, and acetaminophen. An early questionnaire of the value of clinical pharmacy services in a
medical center emergency department setting reported
that clinical pharmacy services added benefit to both
patient care and to educational programs in the department.[16] Eighty-seven percent of the responding physicians reported the pharmacist capable of providing
primary care to specific patients once a physician-based
diagnosis was established. Ninety-five percent of responders believed that clinical pharmacy services could be
transferred to other emergency departments, and 83%
were willing to have their patients charged for clinical
services provided by the pharmacist. A more recent evaluation of the utility of clinical pharmacy services in the
emergency department revealed that provision of a 24hour consultative service by clinical pharmacy residents

117

provided 3.1 consultations per 14-hour call period. Ninety

percent of these consultations were completely followed
by the recipient physician^."^] Clinical pharmacy services
involving a pediatric subspecialty emergency practice has
been described in which a pharmacist is a member of a
pediatric trauma team consisting of a pediatric surgeon,
neurosurgeon, emergency physician, intensivist, radiology
technician, and an intensive care unit nurse.1181
Opportunities for clinical pharmacy service in the
emergency department may expand because of the considerable effects resulting from changes in health insurance provision in the United States focused on reducing the number of hospital admissions. Perhaps the
most prominent example of clinical pharmacy services in
the emergency department setting is related to the management of asthma. The number of asthma-related deaths
in the United States is increasing, especially among
children. One potential cause for this increase may be
inappropriate early discharge of patients from emergency
departments. Pharmacists have participated in interdisciplinary efforts to maximize the urgent care of asthma patients in a number of environments, including the
emergency department. In a university-affiliated urban
teaching hospital, the number of emergency department
visits for a group of asthma patients was significantly
reduced after institution of a comprehensive program of
asthma management."']
Finally, a number of nontraditional practice sites have
been described in which pharmacist have participated in
natural disaster relief or as part of a humanitarian effort
relief team. These nontraditional practices have included
a pharmacy consultative service for wilderness emergency drug planning, pharmacy involvement in emergency preparednesslresponse, the provision of pharmaceutical services at a medical site after Hurricane
Andrew in Florida, and the experience of several pharmacists providing service in B o s n i a - H e r z e g ~ v i n a . ~ ~ ~ - ~ ~ ~
In conclusion, there are numerous current emergency
practice opportunities in which pharmacists play a
significant role. Although the number of pharmacists
who provide clinical services in these settings is relatively
small, the critical nature of drug use in such setting
suggests that the potential for direct pharmacotherapeutic
intervention is large. Well-designed outcome evaluation
of such service is sorely needed.

1. Edwards, G.A.: Samuels, T.M. The role of the hospital

pharmacist in emergency situations. Am. J. Hosp. Pharm.
1968, 25, 128-133.

Cardiac Arrestmmergency Pharmacy Services

I18

2.

X.

9.

10.

I I.

12.

Shimp, L.A.; Mason, N.A.; Tocdter, N.M.: Atwater, C.B.;

Corenflow, D.W. Pharmacist participation in cardiopulmonary resuscitation. Am. J. Health-Syst. Pharm. 1995, 52
(9). 980-984.
Bond. C.A.; Raehl, C.L.; Pitterle, M.E. 1992 National
clinical pharmacy services survey. Pharmacotherapy 199
14 ( 3 ) , 282-304.
Bond, C.A.: Raehl, C.L.; Pittcrlc, M.E. 1992 National
clinical pharmacy services survey. Pharmacotherapy 1998,
18 (2), 302 326.
Bond, C.A.; Raehl, C.L.; Pitterle, M.E. 1992 National
clinical pharmacy services survey. Pharmacotherapy 2000,
20 (4), 436-460.
Elcnbaas, R. Pharmacist on resuscitation team. N. Engl. J.
Med. 1972, 287 ( 3 ) , 151.
Bond, C.A.; Rcahl, C.L. Pharmacists attitudes toward the
use of cardiopulmonary resuscitation training received in
pharmacy school. Am. J. Hosp. Pharm. 1989, 46 (7),
1392- 1394.
White, R.D.; Asplin, B.R.; Bugliosi, T.F.; Hankins, D.G.
High discharge survival rate after out-of-hospital ventricular fibrillation with rapid defibrillation by police and
paramedics. Ann. Emerg. Med. 1996, 28, 480-485.
White, R.D.; Hankins, D.G.; Bugliosi, T.F. Seven years
experience with early defibrillation by police and paramedics in an emergency medical services system. Resuscitation 1998, 39, 145 -151.
Comprehensive Accreditation Manual ,for Hospitals: The
Official Handbook ( C A M H J ,Joint Commission Resources,
Inc.
Ewy, G.A.; Ornato, J.P. 3 I st Bethesda conference.
Emergency cardiac care. Task force 1: Cardiac arrest. J.
Am. Coll. Cardiol. 2000, 35 (4). 832 846.
Edwards, G.A.; Samuels. T.M. The role o l the hospital
pharmacist in emergency situations. Am. J. Hosp. Pharm.
1968. 25 ( 3 ) , 128 133.
Culbertson, V.; Anderson, R.J. Pharmacist involvement in
emergency room services. Contemp. Pharm. Pract. 1981, 4
( 3 ) ; 167- 176.
~

13.

14. Powell, M.F.; Solomon, D.K.; McEachen, R.A. Twentyfour hour emergency pharamaceutical services. Am. J.
Hosp. Pharm. 1985, 42 (4), 831-835.
15. Berry: N.S.; Folstad, J.E.; Bauman, J.L.; Leikin, J.B.
Follow-up observations on 24-hour pharmacotherapy
services in the emergency department. Ann. Pharmacother.
1992, 26 (4), 476 480.
16. Elenbaas, R.M.; Waeckerle, J.F.; McNabney, W.K. The
clinical pharmacist in emergency medicine. Am. J. Hosp.
Pharm. 1977, 34 (X), 843 846.
17. Kasuya, A.; Bauman, J.L.; Curtis, R.A.; Duarte, B.;
Hutchinson, R.A. Clinical pharmacy on-call program in
the emergency department. Am. J. Emerg. Med. 1986, 4
( 5 ) ; 464-461.
18. Vernon, D.D.; Furnival, R.A.; Hansen, K.W.; Dillcr, E.M.;
Bolte, R.G.; Johnson, D.G.; Dcan, J.M. Effect of a
pediatric trauma response tcam on emergency departmcnt
treatment time and mortality of pediatric trauma victims.
Pediatrics 1999, 103 (l), 20 24.
19. Pauuley, T.R.: Magee, M.J.; Cury, J.D. Pharmacistmanaged, physician-directed asthma management program
reduces emergency department visits. Ann. Pharmacother.
1995. 29 (l), 5-9.
20. Closson, R.G. The pharmacist as consultant for wilderness
emergency drug planning. J. Am. Pharm. Assoc. 1977, 17
(12), 746-749.
21. Moore, S.R. Pharmacy involvement in emergency preparednessiresponse. J. R. Soc. Health 1998. 118 (l), 2830.
22. Nestor, A,; Aviles, A.I.; Kummerle, D.R.; Barclay, L.P.;
Rcy, J.A. Pharmaceutical services at a medical site after
hurricane andrew. Am. J. Hosp. Pharm. 1993, 50 (9),
1896-1898.
23. Bussieres, J.F.; St-Arnaud. C.: Schunck, C.; Lamarre, D.;
Jouberton, F. The role of the pharmacist in humanitarian
aid in Bosnia-Herzegovina: The experience of pharmaciens sans frontiers. Ann. Pharmacothcr. 2
112-118.
~

PROFESSIONAL DEVELOPMENT

University of Illinois, Chicago, Illinois, U.S.A.

The roots of the clinical pharmacy movement are firmly

imbedded in cardiology as a discipline. From the bcginning, clinical pharmacists emphasized and specialized in
cardiology pharmacothcrapy. This is not surprising given
several factors: the overall prevalencc of hcart disease in
the United States, the prominence of cardiology as a discipline within medicine, and thc fact that the cornerstone
of the treatment of heart disease is drug therapy. Indeed,
cardiac drugs tend to be complex, rcplete with drug interactions and narrow therapeutic margins and the need
for close therapeutic monitoring, so that contributions by
pharmacists to the care of patients with heart disease seem
to be natural. The exact history of cardiology clinical
pharmacy remains ill-defined, but programs with intensive training in cardiology therapeutics in thc mid- 1970s
were the University of Missouri at Kansas City and the
University of Texas at San Antonio. Of note, E. Grey
Dimond, MD, a founding member of the American College of Cardiology, also initiated the clinical pharmacy
program at Truman Mcdical Center and the University of
Missouri at Kansas City School of Medicine. Strong
training programs (specialized residencies and/or fellowships) subsequently developed in the early 1980s at the
Univcrsity of Tllinois at Chicago, the University of Tcnnessee, and the [Jnivcrsity of Connecticut. Graduates of
these programs in turn seeded many academic health
centers and colleges of pharmacy throughout the United
States. Today, many cardiology clinical pharmacists can
trace their ancestry to a few of these programs.
Cardiology within pharmacy is not a stand-alone specialty. Rather, it is viewed as a subspecialty of sorts within
the umbrella spccialty of clinical pharmacy (or pharmacotherapy). In 2000, the Board of Pharmaceutical Spccialties designated a proccss whereby a board-certified
pharmacotherapy specialist may apply for added qualifications in cardiology pharmacothcrapy practice. The
applicant must submit a portfolio that documents training,
clinical practicc, educational efforts, and scholarly activities (among other details) spccifically within cardiology.
I<nnc.yclopc.diciof Clinical 1~lirrr.rnac.y
DOI: 10.1081E-ECP 120006398
Copyright 0 2003 by Marcel Dckkcr, Inc. All rights reaervcd

For this process to bc approved by the Board of Pharmaceutical Specialties, a petition was submitted (and
subsequently approved) outlining the rationale, necd, and
demographics of the subspecialty, along with appropriate
supporting information. This petition was prepared by the
Cardiology Practice and Research Network (P
American College of Clinical Pharmacy (ACCP); within it
are a number of facts that help to definc the discipline:
1. In 2000, there were about 30 fellowships or specialized residencies in cardiology clinical pharmacy in the United States.
2. About 13% of all board-certified pharmacotherapy
specialists list cardiology as the main emphasis of
their practice.
3. The Cardiology PRN of ACCP has about 400
members, one of the largest subspecialties within
this organization.
4. About 1100 members list cardiology practice as
thcir primary emphasis on membership surveys of
ACCP (750) and the American Society of HealthSystem Pharmacists (350).
5. From a survey of board-certified pharmacothcrapy
specialists performed for the BPS petition for
added qualifications in cardiology, the following
was listcd as the respondents practice area: cardiac intensive care (40%), stcpdown/tclemetry unit
(26%), anticoagulation clinic ( 1 S%,), lipid clinic
(18%), managed care (7%),and other primary care
clinic (35%). Of those responding, 24% had fellowship training, 13% had a specialized residency,
and 19% had complcted a certificate program.

Although the discipline of clinical pharmacy (or pharmacotherapy) within organized medicine is relatively
young, specialized practice in cardiology is one of its more
maturc areas. It is not a stand-alone specialty because one
uses the principles and skills of the specialty pharmacotherapy (as it is presently defined) simply applied to an
area of itnowledge (i.c., cardiology therapeutics). There
are numerous citations documenting the role of and oul119

120

comes (clinical and economic) associated with clinical

pharmacy practice in cardiology settings. These are summarized in the following sections. One will find that the
role of pharmacists providing services to targeted areas
(e.g., lipid clinic, anticoagulation clinic, smoking cessation) in ambulatory settings is much more frequently
studied than the role of the pharmacist practicing in an
acute care, inpatient setting where the clinical functions
are more broad.

ACUTE CARE CARDIOL

Twenty-five percent of Americans discharged from hospitals have a primary diagnosis of cardiovascular (CV)
disease.] The pharmacist practicing in an acute care
setting helps manage common cardiac disease states, including the spectrum of acute coronary syndromes (ACS),
hypertensive emergencies and urgencies, acute heart failure, and cardiac arrhythmias, along with comorbid conditions. Decisions regarding optimal medication use in
such patients are complex. Beginning with the initial
choice of medication to treat a patient acutely, and through
selection of appropriate chronic therapy and proper titration and monitoring, the acute care pharmacist is a vital
component in the system of health care provision.
As part of the health care team, the acute care pharmacist works with attending physicians, physicians-intraining nurses, and other health care professionals to provide patient care. Daily activities are often centered around
medical rounds, where the team reviews each inpatients
progress over the last day. Here, drug therapy decisions are
made within the constructs of a team approach. Information shared during rounds includes results of lab tests,
physical exams, diagnostic and therapeutic procedures,
and symptomatology. Using this information, a pharmacist
assists in evaluating patient response to medications, including assessing dose, route, and monitoring of each drug
that the patient is receiving. When prospectively adding a
medication to the patients orders, the pharmacist recommends appropriate agents based on the clinical indication,
dosing (initial and target), and both efficacy and safety
monitoring parameters. In providing such information, the
pharmacist becomes a primary source of education regarding optimal medication use for all the members of the
health care team. Other tasks the pharmacists might perform include obtaining medication histories from patients
admitted to the hospital, patient medication education, and
discharge counseling for patients discharged from the
hospital on a new medication regimen.
An important role for the pharmacist is prevention of
adverse drug events (ADEs), which significantly contrib-

Cardiology, Clinical Pharmacy Practice in

ute to health care costs in numerous ways, including increases in lengths of stay, medication, and laboratory
costs. Medications used in acute cardiac settings tend to
have narrow therapeutic windows with substantial risk for
toxicity and require close monitoring to optimize therapy
(e.g., antithrombotics, antiarrythmic agents, intravenous
inotropes, nitroprusside). Drug-drug interactions (also
quite common with cardiac regimens), inappropriate dosing, and inappropriate drug selection are just a few examples of common ADEs where pharmacy intervention
could have a tremendous impact. An important study by
Leape et al. noted that the inclusion of a clinical pharmacist on a multidisciplinary team rounding in an intensive care setting reduced ADEs by 66%, through order
clarification, provision of drug information, and recommendations of alternative therapy.[31
A unique responsibility of a cardiology specialty pharmacist is the management of drug therapy of ACS,
particularly those involving unstable angina and cardiac
catheterization-associated procedures. Low-molecularweight heparins and glycoprotein IIb/IIIa receptor antagonists are newer treatment modalities, but are considerably more expensive than older medications used for
ACS. Newer thrombolytics used in treatment of acute
myocardial infarction are easier to administer (in one or
two bolus doses versus an infusion), yet are more expensive. Therefore, there is a need to develop cost-effective
treatment strategies that encompass these newer agents.
These strategies must take into account critical literature
evaluation (i.e., are there superior outcomes between
studies involving the newer agents?) and knowledge of
patient characteristics (i.e., determining if the patient has
an appropriate indication for use of a new therapy, identifying appropriate dosage adjustments in the face of renal
insufficiency) when formulating guidelines. The cardiology specialty pharmacist may play a significant role in
developing such guidelines for the institution, selecting
individual patients for therapy, and selecting which
therapy to use in particular ACS scenarios.
It is common to find a pharmacist as a member of the
hospital cardiopulmonary resuscitation (CPR) team, which
responds to emergent situations that may require immediate patient care. These scenarios usually involve a patient who suddenly becomes nonresponsive, ceases spontaneous respirations, and/or experiences a life-threatening
cardiac arrhythmia. The CPR team responds to such patients by implementing advanced cardiac life support
(ACLS), which involves quick provision of an airway and
electrical (defibrillation) and/or pharmacologic interventions to sustain cardiac function. The pharmacists role on
such a team involves the preparation of intravenous infusions needed in an emergent situation, dose calculations,
and consultation regarding appropriate medication use.

Cardiology, Clinical Pharmacy Practice in

Participation by a pharmacist on a CPR team was associated with significantly lower hospital mortality rates in a
study by Bond and colleagues.[41

121

therapy. In addition, a pharmacist can provide patient

education regarding the importance of compliance, adverse effects, and goals of therapy, thereby increasing the
likelihood of successful control of patients' disease states.

Dyslipidemia
SPECIALTY PRACTICE
In the outpatient setting. cardiology pharmacists frequently provide services in a wide array of clinic types, including general cardiology clinics, primary care/family
medicine clinics, and disease management clinics. The
impact of a cardiology pharmacist in these settings has
been clearly documented in the medical literature. Generally, a pharmacist's knowledge of CV disease state
pathophysiology , presentation, and course, coupled with
extensive knowledge of drug therapy options and monitoring are invaluable insofar as enhancing comprehensive
patient care. The following is a description of types of
specialty care that a pharmacist might provide.

Hypertension
Some of the earliest published reports on the effects of
provision of pharmaceutical care provided insight into the
effects of a pharmacy program in the care of patients with
hypertension. In an early study by McKenney and colleagues, the effects of clinical pharmacy services in a
group of hypertensive patients were d e ~ c r i b e d . ~Those
~]
patients who received pharmacy services in addition to
standard care by their physician demonstrated an improvement in self-knowledge of their disease state, improved compliance. and better blood pressure control.
Subsequent investigations have demonstrated a positive
effect of pharmacy services on cost and quality of life in
patients treated for h y p e r t e n ~ i o n . ' ~ ~ ~ ]
In this largely asymptomatic yet morbid disease, early
identification and treatment are the mainstays for excellent patient care. The proper management of a hypertensive patient begins with selecting an appropriate goal
blood pressure, recognizing other risk factors for CV disease, noting concomitant disease states, and selecting
appropriate drug therapy for the patient. When selecting
such therapy it is important to bear in mind compelling
indications (as defined in the Sixth Report for the Joint
National Committee on the Detection, Evaluation, and
Treatment of High Blood Pressure,"] which is the consensus guidelines for the treatment of hypertension), contraindications or cautions for using certain classes of
medications, patient compliance, and cost. As a drug expert, pharmacists are in an ideal position to enhance care
through the selection and monitoring of antihypertensive

Dyslipidemia is a major risk factor for several CV diseases, including myocardial infarction, stable and unstable angina, and stroke. Control of cholesterol levels is
important in reducing risk of both primary and secondary
CV events. High cholesterol levels may be treated by
altering diet and through pharmacologic intervention.
Outpatient dyslipidemia clinic models that include intervention by a clinical pharmacist have demonstrated
larger reductions in total cholesterol level, greater likelihood for achieving National Cholesterol Education Program"] low-density lipoprotein goals, and better medication compliance."0-'21
The decision to start cholesterol-lowering therapy can
be complex and should involve patient assessment for
concurrent risk factors (hypertension, diabetes), concomitant medications, diet, and social history (alcohol and
cigarette use). The pharmacist can recommend and counsel regarding nonpharmacologic interventions such as reduction in body weight, dietary alterations, exercise, and
cessation of cigarette smoking. It is also important to ensure that comorbid disease states (diabetes, hypertension)
are adequately treated and monitored. If the decision is
made to start a cholesterol-lowering agent, the pharmacist
must ensure that the appropriate agent is selected because
each agent may have a distinct effect on each lipoprotein
component (low density, high density, triglycerides) of
the lipid profile. In addition, prospective identification
and avoidance of drug interactions when using cholesterol-lowering therapy is a salient pharmacist responsibility. For example, IlMG CoA reductase inhibitors (some of
the most commonly used cholesterol-reducing medications) are agents that inhibit a major metabolizing enzyme
in the liver and may be a source of clinically significant
drug interactions, including the occurrence of myositis,
rhabdomyolysis, or renal dysfunction. Recommendation
of pertinent monitoring parameters and patient education
are additional contributions that the clinical pharmacist
can make when caring for the dyslipidemic patient.

Chronic Heart Failure

There are many drug therapy-specific tasks unique to the
care of a heart failure patient. A thorough review of the
medication profile of a patient with heart failure should
include ensuring the presence of appropriate medications

I22

(ACE inhibitors, beta blockers) for reducing mortality

related to this devastating disease. Cardiology pharinacists can optimizc therapy by identifying and achieving
goal doses (those doses achieved in clinical trials of heart
failure) for each of these mcdications, depending on
patient tolerability. Of equal importance is a check for
mcdications that may potentially exacerbate heart Failure
or cause toxicity when given in conjunction with existing
heart failure therapy.
Numerous trials document that many patients do not
always rcccivc drugs shown to decrease mortality in heart
Failure (c.g., ACE inhibitors) or do not rcccivc the proper
("goal") doses (see studics by Smith et al."" and Roe
et a1."41). Clearly, cardiology pharmacists have an impact
on outcomes related to the use of these medications by
ensuring appropriate dosing parameters. Such responsibilities may include recognition of an appropriate patient
for ACE inhibitor or beta blocker therapy, proper uptitration of each agent, management of advcrsc effects related to therapy, and identification of true ACE or beta
blocker intolerance.
Gatlis and colleagues demonstrated the valuable contributions made by a clinical pharmacist in the care of
patients with heart failure.' ''I In this study, pharmacists
made therapy recommendations (including ensuring attainment of goal doses of heart failure medications,
avoidance of contraindicated medications), provided patient education regarding medical therapy, and monitored
for adverse drug events. By providing intensive pharmacy
services, the investigators were able to demonstrate a
reduction in all cause mortality, attainment of higher ACE
inhibitor dose, and greater use of alternate vasodilators in
those patients intolerant to ACE inhibitors.

Antithrombotic therapy is used in myriad CV diseases

such as atrial fibrillation, heart failure, valve replacement,
peripheral vascular disease, and stroke. This presents an
ideal setting for a pharmacist-managed antithrombosis
clinic. Today, inany institutions have antithrombosis clinics managed by clinical pharmacists; this trend continues
to grow.
In such a clinic, a pharmacist is responsible for the
careful, periodic monitoring of prothrombin time (or international norrnalizcd ratio [INRI) to ensurc safe and
efllcacious therapy with oral anticoagulants such as warfarin. In addition, the pharmacist emphasizes patient eduation regarding adverse effects, vitamin K-containing
diets, and potentially interacting drugs. The patient's drug
profile should be reviewed at every visit (for prescription
and over-the-counter medication) to prevent possible drug

Cardiology, Clinical Pharmacy Practice in

interactions. Guidance is also provided to other health care

providers regarding appropriate dosage changes and
monitoring parameters.
Numerous siudies have described clinic models and
outcomes related to pharmacist-managed antithrombosis
clinics. Chiquettc and colleagues demonstrated fewer incidences of supratherapeutic levels of anticoagulation,
more consistent maintenance of appropriate levels of anticoagulation, lower rates of bleeding complications, and
thromboembolic events in a group o f patients managed in
a pharmacist-managed clinic versus those managed by
usual medical care.'
These investigators also showed
lower rates of hospital admissions and emergency dcpartinent visits due to warfarin therapy in those patients managed in the clinic. Similar superior care was noted in investigations published by Wilt and colleagues who also
demonstrated a 20-fold increase in events (warfarin-rclated hospitalization, hemorrhagic or thrombotic events) in
patients cared for in a family practice setting versus a
pharmacist-managed clinic.' 17' Both of these invcstigalions translated these reduced event rates into significant
cost savings; Chiquette estimated annual health care
costs would be reduced by more than $130,000 per 100
patients, whereas Wilt attributed a $4000 cost avoidance
per person-year of follow-up for those patients managed
by a pharmacist.
Other antithrombotic therapies that arc managed by
pharmacists include the oral antiplatclct agents ticlopidine
and clopidigrel, which are used for therapy for ischemic
stroke and postcoronary stent placement. As with warfarin, therapy with these medications requires specific
monitoring (especially of blood counts) and patient education. Another potential role for an antithrombosis pharmacist is management of patients on low-molecularweight heparin (c.g., enoxaparin). As the use of these
agents has expanded to the outpatient setting, particularly
as a transition to oral anticoagulant therapy, the need
exists for a skilled clinical pharmacist to maintain cffcctive and safe treatment with the agents. Dedden and colleaugcs published a report on a pharmacist-managed program to treat proximal deep vein thrombosis."" Patients
were treated at home with enoxaparin and warfarin until
the patient's TNR was therapeutic; all therapeutic monitoring was done by pharmacists. In treating 55 patients, a
total of 294 patient hospital days were avoided, which
could be translated into significant cost savings.

'"

es
Given the many clinical conditions related to or caused by
cardiac conditions combined with the numerous medications used to treat such conditions, it is clear that the po-

123

Cardiology, Clinical Pharmacy Practice in

tential for pharmacist collaboration in the care of cardiology patients is endless. Other clinic types described in
the literature include pharmacist-managed smoking cessation clinics' - 221 amiodarone monitoring clinics,[231
and cardiac medication assistance programsi241(for those
who cannot afford these medications).

NET

TUNlTl

Many cardiology clinical pharmacists collaborate closely

with their physician colleagues in patient care and scho-

Clinical Trials
*Kinetics/Dynamics
.Drug information
4htcomeslEconomi

larly matters. Presentations of the results of major clinical

trials that will influence the daily practice of clinicians
compel many to attend major medical cardiology meetings, such as the annual meetings of the American Heart
Association or the American College of Cardiology, and
follow cardiology specialty journals such as Circulation,
Journal of the American College of Cardiology, American
Journal of Cardiology, and American Heart Journal,
among others. However, the primary forum for networking of cardiology clinical pharmacists is through the
Cardiology PRN of the ACCP. This group meets at the
annual meeting of ACCP, and maintains a useful and ac-

i-\
HMOIMCO

*CHF
*HTN
*Lipids
.Smoking Cessation
*Anti-thrombosis
~Amiodarone

*MI/ACS
.CHF
*HTN
*Arrhythmias
-ACLS

Fig. 1 Representation of the spectrum of cardiology clinical pharmacy practice. Clinical pharmacists may use their skills and knowledge
of the drug treatment of heart disease in a variety of sites (large circles) such as the pharmaceutical industry, health care systems,
ambulatory care, or inpatient settings. Specific duties are listed inside the large circles: they may include the direct care of patients
(inpatient and ambulatory practice) or more global responsibilities for drug use (health care systems and industry), and overlap to some
degree. The smaller circles represent more specific practice sites for each of the respective areas. Abbreviations: HMO, health
maintenance organization; MCO, managed care organization: GPO, group purchasing organization; AHC, academic health center;
Comm, community; Pharm, pharmacy or pharmaceutical; CICU, cardiac intensive care unit; CHF, congestive heart failure; HTN,
hypertension; MI/ACS, myocardial infarctiodacute coronary syndromes; ACLS, advanced cardiac life support (i.e., cardiac arrest team).

124

tive listserv for discussion on therapeutic problems or issues in clinical pharmacy practice.

There are numerous opportunities for cardiology clinical

pharmacists, and these opportunities appear to be expanding (Fig. 1). Traditionally, positions with a predominantly
clinical practice focus were concentrated in academic
medical centers, often those affiliated with a college of
pharmacy. Here, clinicians would practice-either collaboratively (particularly in an inpatient setting) within a
health care team on cardiology units or independently
(particularly in an ambulatory setting)-to manage specialized clinics. Typically, this type of clinician has
teaching duties and some scholarly duties, in addition to
clinical responsibilities. These roles have expanded to
some degree into community hospitals as the clinical
pharmacy movement grew. Further, because of the shift to
managed health care, some clinical pharmacists with skills
in cardiology may take responsibility for the drug use in a
health care system, managing formularies and developing
systemwide treatment guidelines and drug-use policies.
Here, cardiology clinical pharmacists use their skills and
knowledge to effect drug use in populations of patients
with heart disease rather than select individuals.
For positions with a research focus, cardiology clinical
pharmacists (usually with research fellowship training)
have opportunities as clinical science faculty at researchintensive universities (colleges of pharmacy and/or medicine) or in the pharmaceutical industry. In industry positions, cardiology clinical pharmacists may coordinate
clinical trials (phase III and IV) or work in drug disposition and pharmacokinetics. These types of positions
remain, but other opportunities have arisen more recently.
For instance, opportunities in the pharmaceutical industry for medical service managers or medical liaisons
have expanded. These individuals may coordinate some
smaller. single-site research projects (e.g., phase IV),
have educational responsibilities to physicians and pharmacists. and also have a minor sales component within
their duties (or combinations of all of the above, depending
on the specific company). The industry is seeking sophisticated health care professionals who can represent the
company and their products on a sophisticated level; thus,
the cardiology clinical pharmacist seems well suited for
such positions.
Last, there has been an expansion of cardiology clinical pharmacy into ambulatory settings. Due in part to
prospective and fixed payment systems and the growing
sophistication of pharmacists in therapeutic decision mak-

Cardiology, Clinical Pharmacy Practice in

ing, cardiology clinical pharmacists can find opportunities

in managing disease state-specific clinics such as the ones
previously reviewed (e.g., antithrombosis, smoking cessation, heart failure lipid management). Indeed, it has
become very common (if not standard of care) for health
care systems to employ cardiology pharmacists to manage
outpatient antithrombosis treatment (e.g., warfarin, lowmolecular-weight heparin). Usually, this is accomplished
by establishing approved treatment protocols and collaborative drug therapy agreements with physician colleagues. It should be noted that a growing number of states
have passed legislation to allow collaborative drug management by pharmacists (i.e., prescriptive authority under
approved protocols and/or agreements with physicians).
The next frontier is cardiology clinical practice in
community pharmacy settings. It is hoped that the progress
made in ambulatory practice can be extrapolated into these
environments. This possibility has been fueled by demonstration projects where pharmacists receive financial payments for cognitive services. Noteworthy is that some of
these initial disease state management efforts (e.g., management of hypertension, lipid disorders, and thrombosis)
require practice skills and specialized knowledge in cardiovascular pharmacotherapy .

General
American Heart Association web site: www.americanheart .org .

Acute coronary syndromes

Ryan TJ; Antman EM; Brooks NH; Califf RM; Hillis
LD: Hiratzka LF; Rapaport E; Riegel B; Russell RO;
Smith EE 111; Weaver WD. 1999 update: ACC/AHA
guidelines for the management of patients with acute
myocardial infarction: executive summary and recommendations: a report of the American College of Cardiology/American Heart Association Task Force on
Practice Guidelines (Committee on Management of
Acute Myocardial Infarction). Circulation. 1999, 100,
1016- 1030.
Braunwald E; Antman EM; Beasley JW; Califf RM;
Cheitlin MD; Hochman JS; Jones RH; Kereiakes D;
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125

Heart failure
Smith EE 111; Steward DE; Theroux P. ACC/A
2002 Guideline update for the management of patients
* Hunt SA, Baker DW, Chin MH, et al. ACC/AHA
with unstable angina and non-T-segment elevation
guidelines for the evaluation and mangement of
myocardial infarction: a report of the American
chronic heart failure in the adult: a report of the
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sociation Task Force on Practice Guidelines (ComManagement of Patients with Unstable Angina). 2002.
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Available at: http://www.acc,org/clinical/guidelines/
and Management of Heart Failure. 2001. American
unstable/unstable.pdf.
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www .acc.org/clinical/guidelines/failure/hf_index.htm.
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*

Gibbons R9; Chatterjee K; Daley J: et al. ACC/AHA/

ACP-ASIM guidelines for the management of ptients
with chronic stable angina: executive summary and
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Hypertension
e

The Sixth Report for the Joint National Committee on

the Detection, Evaluation, and Treatment of High Blood
Pressure. Arch Intern Med 1 97, 157, 2413-2446.
yslipidemia

Executive Summary of the 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
. 285, 2486-2497.

Anti t hrombotic therapy

* Sixth ACCP Consensus conference on antithrombotic

01, 119 (suppl), 1-370S.
Atrial fibrillation
0

Fuster V, Ryden LE, Asinger RW. Cannom DS, Crijns

HJ. Frye RL. Halperin JL, Kay GN, Klein WW, Levy
S, McNamara RL. Prystowsky EN, Wann LS, Wyse
DG. ACC/AHA/ESC guidelines for the management
of patients with atrial fibrillation: a report of the
American College of Cardiology/American Heart
Association Task Force on Practice Guidelines and
Policy Conferences (Committee to Develop Guidelines for the Management of Patients With Atrial
Fibrillation). J. Am Coll Cardiol 20

Advanced cardiac life support

*

The American Heart Association in Collaboration with

the International Liaison Committee on Resuscitation
(ILCOR). Guidelines 2000 for Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care.
Circulation 2000, 102 (suppl I), 1-1-1-384.

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Practice and Research Network. Executive Summary: Petition for Added Qualifications in Cardiology for Board
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3. Leape. L.L.;
Cullen, D.J.; Clapp, M.D.; Burdick, E.;
Demonaco, H.J.; Erickson, J.I.; Bates, D.W. Pharmacist
participation on physician rounds and adverse drug events
in the intensive care unit. JAMA 1999, 282. 267-270.
4. Bond, C.A.; Raehl, C.L.: Franke, T. Clinical pharmacy
services and hospital mortality rates. Pharmacotherapy
1999, 19: 556-564.
5. McKennep. J.M.; Slining, J.S.: Henderson, H.R.; Devins,
D.; Barr, M. The effect of a clinical pharmacy services on
patients with essential hypertension. Circulation 1973, 48,
1104-1 11 1.
6. Forstrom, M.J.; Ried, L.D.; Stergachis, A.S.: Corliss, D.A.
Effect of a clinical pharmacist program on the cost of
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7. Erickson, S.R.; Slaughter, R.; Halapy, H. Pharmacists
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Arch. Intern. Med. 1997. 157, 2413-2446.
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10. Bogden, P.L.; Koontz, L.M.; Williainson, P.; Abbott, R.D.

The physician and pharinacist teain: An effective approach
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J.S.; Hcckbert, S.R. Tcrnporal patterns in the medical
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Angiotensin converting enzyme inhibitor coinpliancc and
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1s. Gatlis, W.A.; Hasselblad, V.; Whellcn, D.J.; OConnor,
C.M. Reduction in heart failure events by the addition of a
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Dedden, P.; Chang: 3.; Nagel, 1).Pharmacy managed program for home trcatmcnt of deep venous thrombosis with
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Costs and effects associated with a corninunity pharmacybascd smoking cessation programme. Pharmacoeconornics
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Sinclair, H.K.; Bond, C.M.; Lennox. A S . : Silcock, J.;
Winfield, A.J.; Donnan, P.T. Training pharmacists and
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Pharinacotherapy 2001, 21, 1455 1463.

Pt 1ARMACY PRACTICE ISSUES

Cnto Resedrc h Ltd., Durham, North Carolin,i, U.S.A.

Allen Cato
C&o R ~ ~ r Ltd.,
c h San D i c y ~California,
,
U.S.A.

The process of developing a new drug, from the

identification of a potential drug candidate to postmarketing surveillance, is extremely complex. The drug
development process requires input from various members
of a multidisciplinary team and thc conduct of numerous
studies. Thc time from drug discovery to marketing takes
an average of 13 years. Once a chemical is identified as a
new drug candidate, extensive preclinical analyses must be
completed before the drug can be tcstcd in humans. The
pharmacology, toxicology, and prcclinical pharmacokinetics must be characterized. The formulations of the drug
product that were used in the prcclinical studies may be
different from the formulation of the final drug product,
which may require that additional formulation work and
pharmacokinetic analyses be performed. If the characteristics of the new drug candidate are acceptable for all of
thc preclinical assessments, it may then be tested in
humans. The new drug candidate, at this point, enters the
clinical research stage of drug development.
Clinical research represents a vital stagc in thc
development process a stage that is no less daunting than
the preclinical research stagc. The data obtained from the
first-time.-in-human,Phase I pharmacokinetic studies, and
initial safety evaluations in healthy volunteers can make or
break the entire developmental program for a drug
candidate. The sponsoring company, of course: hopes that
the data collected in thesc initial studies will show minimal
safety concerns over an adequate dose range. The
pharmacokinetic data can then be used to help design
future studies in which efficacy and long-term safety arc
assessed and additional pharmacokinetic and pharmacodynamic data are collectcd.
Although the basic designs of the initial single and
multiple dose-escalating studies are generally straightforward (but the starting dose is often intenscly debated), it is
imperative that these studies and future studies be deEizc.yr.lopdici o j Clinic.u/ 1harninc.y
001: 10.108l/E-ECP I2OO06410

Copyright :() 2003 by Marcel Dekker, Inc. All rights rcrcrvccl

signed to address specific questions. The questions vary

depending on numerous specific considerations, including
the targeted disease characteristics (e.g., acute or chronic);
desired safety, efficacy, and pharmacokinetic evaluations;
and assessment of clinical pharmacology (c.g., dosage
formulations or dose frequency). Basic study procedures
must also be considered. Thus, the design, conduct, data
reporting and analysis, and production of the final study
reports can be completed only through the coordinated
efforts of a multidisciplinary drug development team.
For every clinical study, input is required from multiple
personnel with various areas of expertisc. Members of a
drug development teain include physicians, scientists,
pharmacists, project managers, statisticians, computer
programers, study monitors, regulatory experts, and for
some studies, a rcprcsentative of the formulations group.
While some team members may be able to perform
multiple tasks, no one team member has the expertise or
the time to do everything requircd to conduct a clinical
study. In addition, some members may have overlapping
abilities, but other membcrs with particular expertise may
be called upon. For example, pharniacokincticists are
the experts in pharmacokinetics. but thcy may also bc
knowledgeable in pharmaceutics, biostati stics. and clinical
care. Howcvcr, scientists (PhDs) are trained primarily in
basic rescarch, while physicians (MDs) are trained in
clinical medicine. Since a single drug dcvclopmcnt
program is derived from both o f thesc distinct d
considerable ovcrlap, cooperation, and coordination are
necessary to take a drug successfully and efficicntly from
discovery to markct.
Clinical drug development is generally divided into
four phases: Phase 1 through Phase 4. For each study
conducted within a particular phase, specific information
is collectcd according to thc rcquiremcnts for individual
drugs being developed. Collection of safety, efficacy, and
pharmacokinetic data is the focus of most clinical trials.
Although these topics appear to be distinct disciplines,
B 27

12s

they are intertwined and represent different ways of

evaluating the intrinsic properties of a drug. While the
safety, efficacy. and pharmacokinetics of a drug may be
assessed in most studies. the team must establish the type
and extent of information to be collected, which will vary
based upon the specific objectives and designs of the
studies.
A critical function of the drug development team is
the development of the study protocol. The study
protocol must clearly describe the study design and
methodology that will be used to achieve the study
objectives. Input from nonmedical and nonscientific
members of the team, such as marketing and information
technology experts, also is helpful in establishing
development strategies and in designing and conducting
of clinical studies. Finally, project planning efforts can
synchronize team efforts, help contain the soaring costs
of pharmaceutical research: and coordinate international
development efforts.
The drug development teams primary goal is to gain
approval to market the drug, which requires that a
marketing application be submitted to a regulatory
agency (e.g., a New Drug Application [NDA] is
submitted to the Food and Drug Administration [FDA]
in the United States and to the Health Products and Food
Branch [HPFB] in Canada, while a Marketing Authorization Application [MAA] is submitted to European
regulatory agencies). During the conduct of the studies
and the compilation and analyses of the data, the team
must consider and evaluate many issues, such as how to
collect, categorize, and report adverse events. All of
these decisions will affect the marketing application that
is submitted and may ultimately define how the drug is
to be administered.
Many of the decisions to be made by the team, and
particularly by the investigators, pose ethical dilemmas.
Legislation has been enacted to protect human research
subjects. Recently, the most pressing ethical dilemma
facing the clinical research scientist concerned biotechnology and genetic engineering research.
Frequent changes in the regulations and guidelines of
various regulatory agencies, differences in interpretations
of these rules, and special reporting mechanisms for
adverse events represent only a few of the challenges
facing a drug development team. Due to continuous
advances in scientific information, understanding of
disease processes, and gene therapy, change continues to
be the rule in modern drug development. However,
through the efficient application of sound scientific
principles in an ethical manner and with a coordinated
team effort, effective new therapies can continue to be
developed and marketed.

Clinical Evaluation of Drugs

The physicians contribution to drug development and

the physicians role on a drug development team have
changed over the last few decades (1). Before the
1960s, medical departments of pharmaceutical companies were primarily composed of physicians who were
routinely involved in responding to drug information
requests rather than developing new drugs. The
Kefauver-Harris Amendment. enacted in 1962, required
pharmaceutical companies to demonstrate before marketing that a drug was efficacious. which necessitated
that physicians increase their presence on drug
development teams. Along with the advent of additional
governmental regulations, the increase in complexity of
medical knowledge has mandated that physicians
become an integral member of any drug development
team. In fact. because of the different roles of the
physician within an organization. companies may now
have various departments (e.g., a clinical research
department and a clinical safety department) within the
medical department.
Although physicians are trained in patient care,
physicians who are typically employed by pharmaceutical
companies have more training in scientific methodology
than those in the past. The physician on the team is the one
qualified to follow the progress of each patient enrolled in
a clinical trial and to interpret the results. Some physicians
continue to spend time treating patients at a university
hospital or a specific clinic where their specialty can be
utilized and practiced, which allows these physicians to
maintain sharp diagnostic skills. Also, some may perform
basic research in academic settings to develop or maintain
their knowledge and skills in basic research.
However, much of todays clinical research is actually
conducted by investigators who are not employed by
the company sponsoring the development of the drug.
The physician on the drug development team must help
in the selection of appropriate investigators to conduct the
clinical studies. Pharmaceutical physicians may rely on
colleagues who are experts in their respective fields and
who have appropriate patient populations and facilities for
the targeted research project. The physician is also the
expert who deals with emergency situations that may arise
during the course of a clinical research project, such as an
overdose or severe adverse experience (SAE) that might
be experienced with the drug. Similarly. the physician
assists investigators who are responsible for evaluating the
severity of adverse experiences (AEs) and determining

Clinical Evaluation of

the causal relationship of the AEs to the drug under

development.
The physicians involvement in clinical research does
not end with the completion of the clinical study. Medical
reports, clinical study reports, and sections of NDAs must
be written. Interactions with regulatory agencies that
require the physicians input may occur frequently.
Physicians in clinical research may also be called upon
to promote new drugs in a scientific environment by
organizing symposia and workshops and by reviewing
journal advertisements and promotional material for
medical validity and accuracy.
The role of the physician in a clinical drug development
program has expanded and has been refined in the last 40
years. Physicians increasingly contribute clinical and
scientific expertise and administrative skills. Many
physicians on drug development teams today spend most
of their time designing and implementing studies and
interpreting and reporting data rather than being in direct
contact with patients. An experienced clinician is an
important member of any drug development team.

Scientists
While a drug development team may have only one
primary physician, it may have multiple scientists.
Pharmacokineticists, pharmacologists, toxicologists, and
pharmaceutical scientists are all involved in the clinical
development of drugs. The contributions of scientists to a
drug development project are derived from their
experience in both scientific methodology and basic
research (1).
Although physicians are trained in patient care,
scientists are trained in problem-solving skills related to
scientific research. To obtain a doctoral degree, a
scientist must conduct research and write a dissertation
that covers a topic of sufficient scope and depth. During
this process, the scientist learns how to solve problems
from different perspectives. The scientist also collects
extensive data and performs data analyses, thereby
gaining valuable insight into the considerations necessary to determine the feasibility of collecting data in a
clinical trial. Also, some scientists, such as pharmacokineticists with a pharmacy background, may receive
some clinical experience during their training as a
scientist.
Scientists help design major portions of study protocols
and clinical case report forms (CRFs). The study protocol
is the overall plan that the study follows, and it must
contain certain types of information, including the
following: 1) background data on the targeted disease;
2) the empirical and structural formula of the drug being

129

studied; 3) preliminary pharmacology and toxicology of

the drug (specific study objectives and designs); 4) the
methods and materials to be used in the study;
5 ) information regarding drug packaging, labeling, dosage
forms, and decoding procedures; 6) overdose management; 7) patient discontinuation procedures; 8) explanation of informed consent and provisions regarding
institutional review board approval; and 9) any relevant
references and appendices. The CRFs are the forms on
which individual patient data are recorded during a clinical
trial. From these data, clinical and statistical analyses are
performed. All the information that is stipulated in the
study protocol must be collected on the CRFs.
In conjunction with nonscientific personnel, scientists
are responsible for ensuring that the CRFs will capture the
appropriate information for each study subject according
to the objectives, tests, and evaluations stipulated in the
protocol. Careful attention must be given to the
administration of special tests or collection of samples so
that the timing of the assessments or sample collections do
not conflict.
Experience in basic research enables the scientist to
function as an important link between the basic research
labs within the company and the drug development team.
Departments specializing in drug metabolism, microbiology, pharmacology, and toxicology need feedback
from early human safety and pharmacokinetic studies so
they can continue to plan and conduct appropriate longterm animal studies. Thus, communication between the
clinical scientist and the basic scientist is important
throughout the progress of the drug development
program.
Because clinical research has become increasingly
more scientific, experts in the methodology of science are
necessary for a complete research program. The drug
development teams scientists may account for much of
the scientific expertise, but the roles of the research team
overlap to form a scientifically sound, medically astute
cohesive group. In addition to scientific expertise, use of
the scientists administrative talents, such as organizational skills and familiarity with personnel practices,
enables effective drug development. Thus, scientists with
these skills are often employed in management positions in
many organizations.

armacists
The pharmacists role on the drug development team has
greatly expanded the professional opportunities of
individuals with backgrounds in pharmacy. Pharmacists
can provide valuable therapeutic insight into medical
research. Training of pharmacists as clinical scientists with

130

both clinical skills and scientific research skills continues

to be an emphasis at many pharmacy schools. Several
programs have been devised for the education and
development of the pharmacist as clinical scientist ( 2 ) .
Pharmacists have a broad knowledge in both clinical
medicine and pharmaceutics, and therefore are able to
bridge the gap between the clinic and the laboratory.
Pharmacists training focuses on drug therapies in
disease states, whereas physicians training focuses on the
diagnosis of disease states. Studies regarding drug
interaction, positive control, or drug comparison involve
drugs that have been studied and marketed. Pharmacists
can help in the design of such trials because of their
knowledge of marketed drugs.
Additional roles of pharmacists appear in the areas of
drug information and education and training. Pharmacists have the appropriate expertise in drug therapy to
answer inquiries from physicians (and other health
professionals) concerning both marketed and investigational drug products. Similarly, the clinic/laboratory
bridge that the pharmacist builds makes this team
member especially well suited to educate and train new
employees in drug development. By offering both
general and special skills, the research pharmacist
blends clinical medicine with pharmaceutical science
and is well qualified as an educator and drug information
specialist.

Drug development includes many tasks that may not

require the specialized expertise of a physician or a
scientist. Administrative skills, creativity, and excellent
communication abilities, which are qualities not necessarily emphasized within traditional medical and scientific
educational curricula, may be required for many of these
tasks.
The administrative skills necessary for drug development include incorporating seemingly disparate hut vitally
linked concepts into a single overall plan. Integration
planning may mean organizing study files into a logical
sequence or helping to assemble the various parts of an
NDA. In the first example, files must be set up in a way
that can facilitate internal quality assurance audits and
FDA inspections. In the second example, knowledge of the
FDAs regulations and good abstracting capabilities are
required.
Creativity is a quality that cannot be developed through
formal training. Creativity requires bold conjecture and it
expresses itself in newer, better ways to accomplish the
same goals. An example of creativity in clinical drug
research might involve the development of a variable

Clinical Evaluation of Drugs

report that could support all of the different research

documents that are generated by drug research teams.
With such a variable report, common information need not
be recreated each time another document is generated.
Excellent communication skills may be the most
important quality for individuals working in drug
development, even for those with strong medical backgrounds. Clinical research requires extensive interactions
with personnel within the organization and with outside
vendors or clinical sites. The information flow must be
both efficient and accurate. For example, marketing
departments must communicate frequently with medical
departments so that marketing studies, advertising. and
package inserts can be planned and evaluated. Individuals
who lack strong science backgrounds but who have
excellent communication skills often act as liaisons in
these situations.
One aspect of clinical research that requires extensive
contribution by the drug development team personnel is
study monitoring. Study monitors oversee the planning,
initiation, conduct. and data processing of clinical studies
(3). While monitoring studies, monitors must communicate frequently with investigators and help ensure the
data are being collected properly, FDA regulations are
being followed, and any administrative problems are
resolved as quickly as possible. Although monitors
traditionally have had a nonscientific background, many
monitors today have training in the basic sciences, and
some even have advanced degrees, which allows them to
better understand the scientific aspects of the project.
Effective study monitors have a wide range of talents.
The many facets of a clinical research program afford
individuals with varying types of training, education, and
experience, the opportunity to contribute to the drug
development process. Although some tasks clearly require
the clinical or scientific expertise of a physician or a
scientist, other tasks are better suited to those individuals
with less specialized and more general capabilities.

Before clinical drug development can begin, many years

of preclinical development occur, millions of dollars are
spent, and countless decisions are made. Basic research
teams consisting of chemists. pharmacologists, hiologists, and biochemists first identify promising therapeutic categories and classes of compounds. One or
more compounds are selected for secondary pharmacology evaluations and for both acute and subchronic
toxicology testing in animal models. A compound that is

Clinical ~ ~ a ~ u a t of
i oDrugs
n

pharmacologically active and safe in at least two

nonhuman species may then be selected for study in
humans. Before the drug can be tested in humans, an
Investigational New Drug (IND) application, which
contains supporting preclinical information and the
proposed clinical study designs, must be filed with an
appropriate regulatory agency.
Clinical drug development follows a sequential
process. By convention. development of a new drug in
humans is divided into four phases: preapproval segments
(Phases 1 through 3j and a postapproval segment (Phase 4)
(1-4). The definitions of the three preapproval phases
have relatively clear separations. However, the different
phases refer to different types of studies rather than a
specific time course of studies. For example. bioequivalence studies and drug-drug interaction studies are
both Phase 1 studies, but they may be conducted after
Phase 3 studies have been initiated. The generalized
sequence of studies may be tailored to each new drug
during development.

ase
After the appropriate regulatory agency has approved a
potential drug for testing in humans, Phase 1 of the clinical
program begins. The primary goal of Phase 1 studies is to
demonstrate safety in humans and to collect sufficient
pharmacokinetic and pharmacological information to
permit the determination of the dose strength and regimen
for Phase 2 studies.
Phase 1 studies are closely monitored, are typically
conducted in healthy adult subjects, and are designed to
meet the primary goal (i.e., to obtain information on the
safety, pharmacokinetics, and pharmacologic effects of the
drug). In addition. the metabolic profile, adverse events
associated with increasing dosages, and evidence of
efficacy may be obtained. Because most compounds are
available for initial studies as an oral formulation, the
initial pharm-acokinetic profile usually includes information about absorption. Additional studies, such as
drug-drug interactions. assessment of bioequivalence of
various formulations, or other studies that involve normal
subjects, are included in Phase 1.
Generally, the first study in humans is a rising,
single-dose tolerance study. The initial dose may be
based on animal pharmacology or toxicology data, such
as 10% of the no-effect dose. Doses are increased
gradually according to a predetermined scheme, often
some modification of the Fibonacci dose escalation
scheme ( 5 ) , until an adverse event is observed that
satisfies the predetermined criteria of a maximum
tolerated dose (MTD). Although the primary objective

131

is the determination of acute safety in humans, the

studies are designed to collect meaningful pharmacokinetic information. Efficacy information or surrogate
efficacy measurements also may be collected. However,
because a multitude of clinical measurements and tests
must be performed to assess safety, measurements of
efficacy parameters must not compromise the collection
of safety and pharmacokinetic data.
Appropriate biological samples for pharmacokinetic
assessment, typically blood and urine. should be
collected at discrete time intervals based upon extrapolations from the pharmacokinetics of the drug in animals.
Depending on the assay sensitivity, the half-life and
other pharmacokinetic parameters in healthy volunteers
should be able to be evaluated, particularly at the higher
doses. The degree of exposure of the drug is an
important factor in understanding the toxicologic results
of the study. Pharmacokinetic linearity (dose linearity) or
nonlinearity will be an important factor in the design of
future studies.
Once the initial dose has been determined, a placebocontrolled, double-blind, escalating single-dose study is
initiated. Generally, healthy male volunteers are
recruited, although patients sometimes are used (e.g.,
when testing a potential anticancer drug that may be too
toxic to administer to healthy volunteers). These studies
may include two or three cohorts, with six or eight
subjects receiving the active drug and two subjects
receiving placebo. The groups may receive alternating
dose levels, which allow assessment of dose linearity,
intrasubject variability of pharmacokinetics, and doseresponse (i.e., adverse events) relationship within
individual subjects.
Participants in the first study are usually hospitalized or
enrolled in a clinic so that clinical measurements can be
performed under controlled conditions and any medical
emergency can be handled in the most expeditious
manner. This study is usually placebo-controlled and
double-blinded so that the drug effects, such as druginduced ataxia, can be distinguished from the nondrug
effects, such as ataxia secondary to viral infection. The
first study in humans is usually not considered successfully
completed until an MTD has been reached. An MTD must
be reached because the relationship between a clinical
event (e.g., emesis) and a particular dose level observed
under controlled conditions can provide information that
will be extremely useful when designing future trials.
Also, the dose range and route of administration should be
established during Phase 1 studies.
A multiple-dose safety study typically is initiated once
the first study in humans is completed. The primary goal
of the second study is to define an MTD with multiple

Clinical Evaluation of Drugs

132

dosing before to initiating well-controlled efficacy testing.

The study design of the multiple-dose safety study should
simulate actual clinical conditions in as many ways as
possible; however, scientific and statistical validity must
be maintained. The inclusion of a placebo group is
essential to allow the determination of drug-related versus
nondrug-related events. The dosing schedule, which
includes dosages, frequency, dose escalations, and dose
tapering, should simulate the regimen to be followed in
efficacy testing.
Typically, dosing in the second study lasts for 2 weeks.
The length of the study may be increased depending on the
pharmacokinetics of the drug so that both drug and
metabolite concentrations reach steady state. Also, if the
drug is to be used to treat a chronic condition, a 4-week
study duration may be appropriate. To obtain information
for six dose levels with six subjects receiving active drug
and two receiving placebo for each of two cohorts, a
minimum enrollment of 24 subjects should be anticipated.
Similar to the first study in humans, these subjects would
be hospitalized for the duration of the study.
Also similar to the first study, pharmacokinetic data
must be obtained. These data will be used to help determine
dosage in future efficacy trials. The new pharmacokinetic
information that can be gathered includes the following:
1) determination regarding whether the pharmacokinetic
parameters obtained in the previous acute safety study
accurately predicted the multiple dose pharmacokinetic
behavior of the drug; 2) verification of pharmacokinetic
linearity (i.e., dose proportionality of C,,
and AUC)
observed in the acute study; 3) determination regarding
whether the drug is subject to autoinduction of clearance
upon multidosing; and 4) determination of the existence
and accumulation of metabolites that could not be detected
in the previous single-dose study. A number of
experimental approaches can be used to gather this
information, and all require frequent collection of blood
and urine samples. The challenge to the clinical
pharmacokineticist is to design an appropriate blood
sample collection schedule that will maximize the
pharmacokinetic information, yet can be gathered without
biasing the primary objective-determination
of clinical
safety parameters.

After the initial introduction of a new drug into humans,

Phase 2 studies are conducted. The focus of these Phase 2
studies is on efficacy, while the pharmacokinetic
information obtained in Phase 1 studies is used to
optimize the dosage regimen. Phase 2 studies are not as
closely monitored as Phase 1 studies and are conducted in

patients. These studies are designed to obtain information

on the efficacy and pharmacologic effects of the drug, in
addition to the pharmacokinetics. Additional pharmacokinetic and pharmacologic information collected in Phase 2
studies may help to optimize the dose strength and
regimen and may provide additional information on the
drugs safety profile (e.g., determine potential drug-drug
interactions).
Efficacy trials should not to be initiated until the MTD
has been defined. In addition, the availability of
pharmacokinetic information in healthy volunteers is key
to the design of successful efficacy trials. The clinical
pharmacokineticist assists in the design and execution of
these trials and analyzes the plasma drug concentration
data upon completion of the efficacy studies.
During the planning stage of an efficacy trial, the focus
is on the dosage regimen and its relationship to efficacy
measurements. Plasma drug concentrations for various
dosages can be simulated based upon the data collected in
the first two studies in humans. The disease or
physiological states of the test patients (e.g., organ
dysfunction as a function of age), concurrent medications
(e.g., enzyme inducers or inhibitors), and the safety data
obtained earlier must be considered when choosing an
optimal dosage regimen for the study. In addition, if the
targeted site of the drug is in a tissue compartment,
theoretical drug levels in this compartment can be
simulated, which may help scientists determine the
appropriate times for efficacy measurements.
On completion of the efficacy trial, a therapeutic
window for plasma drug concentrations can be defined by
reviewing the correlation between plasma drug concentrations and key safety and efficacy parameters. The goal is
to improve efficacy and safety of the drug by
individualizing the dosage based upon previous plasma
drug concentration profiles in the same patient.

Phase 3
If the earlier clinical studies establish a drugs therapeutic,
clinical pharmacologic, and toxicologic properties and if it
is still considered to be a promising dmg-Phase 3 clinical
trials will be initiated. Phase 3 studies enroll many more
patients and may be conducted both in a hospital or
controlled setting and in general practice settings. The
goals of Phase 3 studies are to confirm the therapeutic
effect, establish dosage range and interval, and assess
long-term safety and toxicity. Less common side effects
and AEs that develop latently may be identified. In
addition, studies targeted to evaluate and quantify specific
effects of the drug, such as drowsiness or impaired
coordination, are conducted during this phase.

Computer Software for Clinical ~ ' h ~ r m a cServices

y

218

Table 2

Installed base and functionality offered

a,

Computer Software for Clinical Pharmacy Services

219

Table 2 Installed base and functionality offered (Continued)

Functionality
Footnotes
1 Internet-based Medicare billing
and CMN documentationnlanagement system. Markets
served also include infiision
pharmacy
2 IVR system designed to Pandle
electronic prescriptions and
interface with central-processing
and central-fill systems
3 Chain cential management for
POS system
4 Installations represent primarily
large. long-term-care proiiders.
Also serve correctional institutions.
5 Database for front-store systems
6 Medication-compliance system.
7 Clinical drug data.
6 Chain centrai mananement for
POS system
9 Also systems to LTC market and
offers ASP service
13 Also have installations at military
locations.
11 Systems also installed in clinics,
correctional institutions. and
long-term-care facilities
12 Clinical drug data
13 Also serve HME pharmacy market. with biliing service that has
8,422 clients.
14 Aiso have systems installed in
veterinary practices.
15 Products use by Dept of
DefenseNA as well Company
seils software-driven warning
iabels
16 Company is dedicated soley to
tile long-term-care market
Installation figure represent 6,664
users serving in excess of 1 million LTC beds All functionalitv
offered is for long-term-care
pharmacy. Chain instaliations
represent long-term-care chain
providers.
17 Represents installations cf
barcode scanning fcr data entry
and verification
IS Company specializes in POS
s y s m s Chair central nianagement is for POS system.
19 Customized pricing service ior
retail pharmacy.
20 Chain central management
system will be released Nov
2001
22 Web design and management for
retail pharmacy. 1ns:allations
represenl CornerDrugstore com
sites.
23 A core product is an ASP service.
24 Data :onversion and databasemanagement sewices.
LEGEND
ii: = interface
r/a = 10" aijDlicaale
ris = no; spec lied
uid = dndei development

220

work, new and unique hardware challenges will be presented. Bandwidth to the home represents one of the greatest challenges for telecommuting. Services such as DSL
and cable modems offer potential solutions to this bandwidth problem. Productivity gains as high as 30 percent
are reported as an incentive for investigation of this area.

Computer Software for Clinical Pharmacy Services

of simply ignoring them. System oversight for monitoring

the potential of medication error should occur throughout
the process, beginning with point-of-prescribing through
point-of-administration. Bar codes and other technologies
will be needed to facilitate this process.

DOCUMENTATION
If one asks the question. What is my computer supposed
to be doing when Im providing pharmaceutical care?
the answer will not only describe the appropriate hardware
or device that matches the needs of the professional
providing the care, but should also describe the optimal
software that will support the provision of pharmaceutical
care. We define the point-of-care as the place where a
pharmacist provides pharmaceutical care to a patient or
assists a colleague (pharmacist, physician, or nurse) in the
provision of care. Many kinds of software available on the
market today focus solely on transaction processing, with
minimal decision support available through prospective
drug utilization review (DUR) modules.
Because the clinical environment demands real-time or
near-real-time decisions, a different kind of computer
support is required. Pharmacy is like other healthcare
disciplines in that we face the problem of having large
volumes of information but a lack of information services
that are able to translate this information into better outcomes for patients.r21A clinical practitioner requiring decision support wants this support to be presented in a
succinct manner that facilitates a timely response to the
problems routinely encountered in his or her practice.
Specific characteristics of successful decision-support
systems include the provision of patient-specific recommendations, delivery of measurable time savings, and
seamless integration into the daily work activities of the
clinical ~ e t t i n g . ~
Documentation
]
should occur as a byproduct of the interactions between clinical practitioners
and their patients or clients. Access to patient records
should not only be provided instantaneously through
electronic means, but the ability to customize the information provided into a format desired by the individual
practitioner should be allowed. When pharmacokinetic
calculations are required, known demographic values
such as body weight or serum creatinine levels should be
prepopulated into calculation variables.
Clinicians will often desire to examine historical data or
use relevant references, or primary or secondary literature
sources. The software design should include these aspects
at a minimum. When prospective drug utilization review
flags are presented, false positive warnings should be
minimal to prevent practitioners from getting in the habit

It has been said, If you didnt document it, you didnt

do it. In the litigious environment in which we live,
documentation is paramount to professional survival.
Without documentation, reimbursement can be challenged. Personnel reductions are almost assured without
documentation to demonstrate the impact of clinical
services. Without documentation, unnecessary redundancies and events will be exacerbated.
Ideally, documentation should occur as a natural byproduct of rendering care to patients. In these times where
the integration of care (care management) is being sought,
the ability of clinical software to access and populate a
clinical data repository is a key evaluation criterion.
Increasingly, integration with clinical practice protocols
is facilitating more effective and more comprehensive
delivery of care. A major question is, Will the patient and
the profession of pharmacy be best served by accessing,
on a read/write basis, an electronic medical record that is
seen by all other disciplines, or should pharmacists to
continue to have a pharmacy-specific software solution?
It may be mission critical to the profession for pharmacists to gain or maintain read/write privileges where
all pharmaceutical care contributions can be viewed by
all caregivers. Additionally. pharmacists will need to be
able to access diagnosis, laboratory, and other charted information such as demographics on a common medical
record. Thus, at a minimum, it will be necessary for all
pharmacy software to be able to be integrated into the
electronic medical records as they emerge.
Orthopedics has recognized the importance of measuring outcomes in terms of quality-adjusted life-years instead of length of implant survival.21Similarly, pharmacy
must implement software documentation solutions that
facilitate outcomes monitoring beyond cost savings.
Software is needed with the ability to calculate, in a costbenefit analysis, the clinical impact of pharmacist interventions as they affect therapeutic, financial, and humanistic outcomes. The current array of products could be
better integrated into documentation software to facilitate
tabulation of these data. With the power of the Internet to
manipulate data in a dynamic database, it would even be
possible for hospitals to compare their outcomes on a local,
regional, or national basis. Furthermore, the database could

Biopharmaceutics

Table 4

91

Drug absorption in the gastrointestinal tract (Continued)

Function

Affect on drug absorption

The rectum is about 15 cm long, ending at the anus.

In the absence of fecal material, the rectum has a
small amount of fluid, (about 2 m) with a pH about 7.
The rectum is perfused by the superior, middle, and
inferior hemorrhoidal veins. The inferior hemorrhoidal
vein (closest to the anal sphincter) and the middle
hemorrhoidal vein feed into the vena cava and back to
the heart. The superior hemorrhoidal vein joins the
mesenteric circulation, which feeds into the hepatic
portal vein and then to the liver.

Drug absorption may be variable depending upon the

placement of the suppository or drug solution within
the rectum. A portion of the drug dose may be
absorbed via the lower hemorrhoidal veins, from
which the drug feeds directly into the systemic
circulation; some drug may be absorbed via the
superior hemorrhoidal veins, which feeds into the
mesenteric veins to the hepatic portal vein to the
liver, and metabolized prior to systemic absorption.

Anatomic area
Rectum

Some drugs may be absorbed into the lymphatic

circulation through the lacteal or lymphatic vessels under
the microvilli. Absorption of drugs through the lymphatic
system bypasses the first-pass effect due to liver
metabolism, because drug absorption through the hepatic
portal vein is avoided. The lymphatics are important in the
absorption of dietary lipids and may be partially
responsible for the absorption for some lipophilic drugs
such as bleomycin or aclarubicin which may dissolve in
chylomicrons and be systemically absorbed via the
lymphatic system.

Effect of food and other factors

on GI drug absorption
Digested foods may affect intestinal pH and solubility of
drugs. Food effects are not always predictable. The
absorption of some antibiotics (e.g., penicillin, tetracycline) is decreased with food, whereas other drugs (e.g.,
griseofulvin) are better absorbed when given with food
containing a high fat content. Food in the GI lumen
stimulates the flow of bile. Bile contains bile acids. Bile
acids are surfactants are involved in the digestion and
solubilization of fats, and increases the solubility of fatsoluble drugs through micelle formation. For some basic
drugs (e.g., cinnarizine) with limited aqueous solubility,
the presence of food in the stomach stimulates
hydrochloric acid secretion, which lowers the pH, causing
more rapid dissolution of the drug and better absorption.
Generally, the bioavailability of drugs is better in
patients in the fasted state and with a large volume of water
(Fig. 5). However, to reduce GI mucosal irritation, drugs
such as erythromycin, iron salts, aspirin, and nonsteroidal
anti-inflammatory agents (NSAIDs) are given with food.
The rate of absorption for these drugs may be reduced
in the presence of food, but the extent of absorption may be
the same.

The drug dosage form may also be affected by food. For

example, enteric-coated tablets may stay in the stomach
for a longer period of time because food delays stomach
emptying. If the enteric-coated tablet does not reach the
duodenum rapidly, drug release and subsequent systemic
drug absorption are delayed. In contrast. enteric-coated
beads or microparticles disperse in the stomach, are less
affected by food, and demonstrate more consistent drug
absorption from the duodenum.
Food may also affect the integrity of the dosage form,
causing an alteration in the release rate of the drug.
For example, theophylline bioavailability from Theo-24
controlled-release tablets is much more rapid (7)
when given to a subject in the fed rather than fasted
state (Fig. 6).
Some drugs, such as ranitidine, cimetidine, and
dipyridamole, after oral administration produce a blood
concentration curve consisting of two peaks. This
double-peak phenomenon is generally observed after
the administration of a single dose to fasted patients. The
rationale for the double-peak phenomenon has been
attributed to variability in stomach emptying, variable
intestinal motility, presence of food, enterohepatic
recycling, or failure of a tablet dosage form. For a
drug with high water solubility, dissolution of the drug
occurs in the stomach, and partial emptying of the drug
into the duodenum will result in the first absorption peak.
A delay in stomach emptying results in a second
absorption peak as the remainder of the dose is emptied
into the duodenum.
Diseases such as Crohns disease that alter GI
physiology and corrective surgery involving peptic ulcer,
antrectomy with gastroduodenostomy and selective
vagotomy may potentially affect drug absorption. Drug
absorption may be unpredictable in many disease
conditions. Drugs or nutrients or both may also affect
the absorption of other drugs. For example, propantheline

Biopharmaceutics

92

54
34
r-

.4
&L

!4
4
4

5 6 4 !

r-

? % !

6 4 !

Fig. 5 Mean plasma or serum drug levels in healthy, fasting human volunteers ( n = 6 in each case) who received single oral doses of
aspirin (650 mg) tablets, erythromycin stearate (500 mg) tablets, amoxicillin (500 mg) capsules, and theophylline (260 mg) tablets,
together with large. (From Welling P.G.; Drug Bioavailability and Its Clinical Significance. Progress in Drug Metabolism, Vol. 4;
Bridges K.W.; Chassea, VD LF. Eds.; Wiley; London, 1980.)

bromide is an anticholinergic drug that slows stomach

emptying and motility of the small intestine and may
reduce stomach acid secretion. Grapefruit juice was found
to increase the plasma level of many drugs due to
inhibition of their metabolism in the liver.

suspension, suppository), 2 ) the nature of the excipients

in the drug product, 3) the physicochemical properties
of the drug molecule, and 4) the route of drug
administration.

Disintegration

Biopharmaceutic considerations in the design and

manufacture of a drug product to deliver the active
drug with the desired bioavailability characteristics
include: 1) the type of drug product (e.g., solution,

Immediate release, solid oral drug products must rapidly

disintegrate into small particles and release the drug. The
United States Pharmacopoeia (USP) describes an official
tablet disintegration test. The process of disintegration
does not imply complete dissolution of the tablet and/or
the drug. Complete disintegration is defined by the USP as
that state in which any residue of the tablet, except
fragments of insoluble coating, remaining on the screen of

Biopharmaceutics

3t

93

# 8

of the rate of drug diffusion from the surface to the bulk of

the solution. In general, drug concentration at the surface
is assumed to be the highest possible, i.e., the solubility of
the drug in the dissolution medium. The drug concentration C is the homogeneous concentration in the bulk
solution which is generally lower than that in the stagnant
layer immediate to the surface of the solid. The decrease in
concentration across the stagnant layer is called the
diffusion gradient
dCldt = DA(CS - C)h

!,

&!

,4

,6

35

54

Fig. 6 Theophylline serum concentration in an individual

subject after a single 1500 mg dose of Theo-24 taken during
fasting, period during which this patient experienced nausea,
repeated vomiting, or severe throbbing headache. The pattern of

drug release during the food regimen is consistent with dosedumping. (From Ref. 7.)
the test apparatus in the soft mass have no palpably firm
core. The USP provides specifications for uncoated
tablets, plain coated tablets, enteric tablets, buccal tablets,
and sublingual tablets. Exempted from USP disintegration
tests are troches, tablets which are intended to be chewed,
and drug products intended for sustained release or
prolonged or repeat action.
Disintegration tests allow for precise measurement of
the formation of fragments, granules, or aggregates from
solid dosage forms, but do not provide information on the
dissolution rate of the active drug. The disintegration test
serves as a component in the overall quality control of
tablet manufacture.

Dissolution
Dissolution is the process by which a chemical or drug
becomes dissolved in a solvent. In biologic systems, drug
dissolution in an aqueous medium is an important prior
condition of systemic absorption. The rate at which drugs
with poor aqueous solubility dissolve from an intact or
disintegrated solid dosage form in the GI tract often
controls the rate of systemic absorption of the drug. Thus,
dissolution tests are discriminating of formulation factors
that may affect drug bioavailability.
As the drug particle dissolves, a saturated solution
(stagnant layer) is formed at the immediate surface around
the particle. The dissolved drug in the saturated solution
gradually diffuses to the surrounding regions. The overall
rate of drug dissolution may be described by the NoyesWhitney equation which models drug dissolution in terms

where, dCldt = rate of drug dissolution, D = diffusion rate

constant, A = surface area of the particle, CS = drug
concentration in the stagnant layer, C = drug concentration in the bulk solvent, and h = thickness of the
stagnant layer.
The rate of dissolution, (dCldt) X (UA), is the amount
of drug dissolved per unit area per time (e.g., g/cm2 per
min).
The Noyes-Whitney equation shows that dissolution
rate is influenced by the physicochemical characteristics of
the drug, the formulation, and the solvent. In addition, the
temperature of the medium also affects drug solubility and
dissolution rate.

~iubility,pH, an
The natural pH environment of the GI tract varies from
acidic in the stomach to slightly alkaline in the small
intestine. Drug solubility may be improved with the
addition of acidic or basic excipients. Solubilization of
aspirin, for example, may be increased by the addition of
an alkaline buffer. Controlled release drug products are
nondisintegrating dosage forms. Buffering agents may be
added to slow or modify the release rate of a fastdissolving drug in the formulation of a controlled release
drug product. The buffering agent is released slowly rather
than rapidly so that the drug does not dissolve immediately
in the surrounding GI fluid. Intravenous drug solutions are
difficult to prepare with drugs that have poor aqueous
solubility. Drugs that are physically or chemically unstable
may require special excipients, coating or manufacturing
process to protect the drug from degradation.

Stability, pH, and Dru

rptio

The pH-stability profile is a plot of reaction rate constant

for drug degradation versus pH and may help to predict if

94

Biopharmaceutics

some of the drug will decompose in the GI tract. The

stability of erythromycin is pH-dependent. In acidic
medium, erythromycin decomposition occurs rapidly,
whereas at neutral or alkaline pH the drug is relatively
stable. Consequently, erythromycin tablets are enteric
coated to protect against acid degradation in the stomach.
In addition, less soluble erythromycin salts that are more
stable in the stomach have been prepared.

Particle
The effective surface area of the drug is increased
enormously by a reduction in the particle size. Because
drug dissolution is thought to take place at the surface of
the solute, the greater the surface area, the more rapid the
rate of drug dissolution. The geometric shape of the drug
particle also affects the surface area, and during
dissolution the surface is constantly changing. In
dissolution calculations, the solute particle is usually
assumed to have retained its geometric shape.
Particle size and particle size distribution studies are
important for drugs that have low water solubility. Particle
size reduction by milling to a micronized form increased
the absorption of low aqueous solubility drugs such as
griseofulvin, nitrofurantoin, and many steroids. Smaller
particle size results in an increase in the total surface area
of the particles, enhances water penetration into the
particles, and increases the dissolution rates. With poorly
soluble drugs, a disintegrant may be added to the
formulation to ensure rapid disintegration of the tablet
and release of the particles.

Fig. 7 Comparison of mean blood serum levels obtained with

chloramphenicol palmitate suspensions containing varying ratios
of 01 and p polymorphs, following single oral dose equivalent.
(From Ref. 9.)

change in crystal structure of the drug may cause cracking

in a tablet or even prevent a granulation to be compressed
into a tablet requiring reformulation of the product. Some
drugs interact with solvent during preparation to form a
crystal called solvate. Water may form a special crystal
with drugs called hydrates, for example, erythromycin
forms different hydrates (8) which may have quite different
solubility compared to the anhydrous form of the drug
(Fig. 8). Ampicillin trihydrate, for example, was reported

Polymorphic Crystals, Solvates,

and Drug Absorption
Polymorphism refers to the arrangement of a drug in
various crystal forms (polymorphs). Polymorphs have the
same chemical structure but different physical properties,
such as solubility, density, hardness, and compression
characteristics. Some polymorphic crystals may have
much lower aqueous solubility than the amorphous forms,
causing a product to be incompletely absorbed. Chloramphenicol(9), for example, has several crystal forms, and
when given orally as a suspension, the drug concentration
in the body depended on the percentage of P-Polymorph in
the suspension. The @-form is more soluble and better
absorbed (Fig. 7). In general, the crystal form that has the
lowest free energy is the most stable polymorph.
Polymorphs that are metastable may convert to a more
stable form over time. A crystal form change may cause
problems in manufacturing the product. For example, a

'44
64

-4

'4

!4

&4

,4

34

54

Fig. 8 Dissolution behavior of erythromycin dihydrate,

monohydrate, and anhydrate in phosphate buffer (pH 7.5) at
37C. (From Ref. 8.)

Biopharmaceutics

Table 5

95

Table 6

Common excipients used in solid drug products

Excipient

Excipient

Property in dosage form

Lactose
Dibasic calcium phosphate
Starch
Microcrystalline cellulose
Magnesium stearate
Stearic acid
Hydrogenated vegetable oil
Talc
Sucrose (solution)
Polyvinyl pyrrolidone (solution)
Hy droxypropy lmethylcellulose
Titinium dioxide
Methylcellulose
Cellulose acetate phthalate

Common excipients used in oral liquid drug products

Diluent
Diluent
Disintegrant, diluent
Disintegrant, diluent
Lubricant
Lubricant
Lubricant
Lubricant
Granulating agent
Granulating agent
Tablet-coating agent
Combined with dye as
colored coating
Coating or granulating agent
Enteric coating agent

Property in dosage form

Sodium carboxymethylcellulose
Tragacanth
Sodium alginate
Xanthan gum
Veegum
Sorbitol
Alcohol
Propylene glycol
Methyl propylparaben
Sucrose
Poly sorbates
Sesame oil
Corn oil

Suspending agent
Suspending agent
Suspending agent
Thixotropic
suspending agent
Thixotropic
suspending agent
Sweetener
Solubilizing agent,
preservative
Solubilizing agent
Preservative
Sweetener
Surfactant
For emulsion vehicle
For emulsion vehicle

(From Ref. 1.)

(From Ref. 1.)

to be less absorbed than the anhydrous form of ampicillin

due to faster dissolution of the latter.

Excipients are pharmacodynamically inactive substances

that are added to a formulation to provide certain
functional properties to the drug and dosage form.
Excipients may be added to improve the compressibility
of the active drug, stabilize the drug from degradation,
decrease gastric irritation, control the rate of drug
absorption from the absorption site, increase drug
bioavailability, etc. Some excipients used in the

Table 7

manufacture of solid and liquid drug products are

listed in Tables 5 and 6. For solid oral dosage forms
such as compressed tablets, excipients may include
1) diluent (e.g., lactose), 2) disintegrant (e.g., starch),
3) lubricant (e.g., magnesium stearate), and 4) other
components such as binding and stabilizing agents.
When improperly used in the formulation, excipients
may alter drug bioavailability and possibly pharmacodynamic activity.
Excipients may affect the drug dissolution rate by
altering the medium in which the drug is dissolving or
by reacting with the drug itself. Some common
manufacturing problems that affect drug dissolution
and bioavailability are listed in Table 7. For example,

Effect of excipients on the pharmacokinetic parameters of oral drug producta

Excipients

Example

Disintegrants
Lubricants
Coating agent
Enteric coat
Sustained-release agents
Sustained-release agents (waxy agents)
Sustained-release agents (gudviscous)

Avicel, Explotab
Talc, hydrogenated vegetable oil
Hydroxypropylmethyl cellulose
Cellulose acetate phthalate
Methylcellulose, ethylcellulose
Castorwax, Carbowax
Veegum, Keltrol

"This may be concentration and drug dependent.

1= Increase, = decrease, - = no effect. k , = absorption rate constant, t,,,
drug concentration time curve.
(From Ref. 1.)

ka

tmax

t
t
t
T

c
c
c

AUC

= time for peak drug concentration in plasma, AUC = area under the plasma

96

suspending agents increase the viscosity of the drug

vehicle, but may decrease the drug dissolution rate from
the suspension. An excessive quantity of magnesium
stearate (a hydrophobic lubricant) in the formulation
may retard drug dissolution and slow the rate of drug
absorption. The total amount of drug absorbed may also
be reduced. To prevent this problem, the lubricant level
should be decreased or a different lubricant selected.
Sometimes, increasing the amount of disintegrant may
overcome the retarding effect of lubricants on
dissolution. However, with some poorly soluble drugs
an increase in disintegrant level has little or no effect
on drug dissolution because the fine drug particles are
not wetted. The general influence of some common
excipients on drug bioavailability parameters for typical
oral drug products is summarized in Table 7.
Excipients may enhance or diminish the rate and
extent of systemic drug absorption. Excipients that
increase the aqueous solubility of the drug generally
increase the rate of drug dissolution and absorption. For
example, sodium bicarbonate in the formulation may
change the pH of the medium surrounding the active
drug substance. Aspirin, a weak acid, in an alkaline
medium will form a water-soluble salt in which the drug
rapidly dissolves. This process is known as dissolution in
a reactive medium. The solid drug dissolves rapidly in
the reactive solvent surrounding the solid particle. As the
dissolved drug molecules diffuse outward into the bulk
solvent, the drug may precipitate out of solution with a
very fine particle size. The small particles have
enormous collective surface area and disperse and
redissolve readily for more rapid absorption on contact
with the mucosal surface.
Excipients may interact directly with the drug to form a
water-soluble or water-insoluble complex. If tetracycline
is formulated with calcium carbonate, an insoluble
complex of calcium tetracycline is formed that has a
slow rate of dissolution and poor absorption.
Excipients may increase the retention time of the
drug in the GI tract and therefore increase the amount
of drug absorbed. Excipients may act as carriers to
increase drug diffusion across the intestinal wall. The
addition of surface-active agents may increase wetting
as well as solubility of drugs. In contrast, many
excipients may retard drug dissolution and thus reduce
drug absorption.
Shellac used as a tablet coating, upon aging, can
slow the drug dissolution rate. Surfactants may affect
drug dissolution in an unpredictable fashion. Low
concentrations of surfactants lower the surface tension
and increase the rate of drug dissolution, whereas higher
concentrations of surfactants tend to form micelles with

Biopharmaceutics

the drug and thus decrease the dissolution rate. High

tablet compression without sufficient disintegrant may
cause poor disintegration in vivo of a compressed
tablet.

A dissolution test in vitro measures the rate and extent of

dissolution of the drug in an aqueous medium in the
presence of one or more excipients contained in the drug
product. A potential bioavailability problem may be
uncovered by a suitable dissolution method. The optimum
dissolution testing conditions differ with each drug
formulation. Different agitation rates, different medium
(including different pH), and different dissolution
apparatus should be tried to distinguish which dissolution
method is optimum for the drug product and discriminating for drug formulation changes. The appropriate
dissolution test condition for the drug product is then
used to determine acceptable dissolution specifications.
The size and shape of the dissolution vessel may
affect the rate and extent of dissolution. For example, the
vessel may range in size from several milliliters to
several liters. The shape may be round-bottomed or flat,
so that the tablet might lie in a different position in
different experiments. The amount of agitation and the
nature of the stirrer affect the dissolution rate. Stirring
rates must be controlled, and specifications differ
between drug products. Low stirring rates (SO- 100 rpm)
are more discriminating of formulation factors affecting
dissolution than higher stirring rates. The temperature of
the dissolution medium must be controlled and variations
in temperature must be avoided. Most dissolution tests
are performed at 37C.
The nature of the dissolution medium, the solubility of
the drug and the amount of drug in the dosage form will
affect the dissolution test. The dissolution medium should
not be saturated by the drug. Usually, a volume of medium
larger than the amount of solvent needed to completely
dissolve the drug is used in such tests. The usual volume of
the medium is 500- 1000 ml. Drugs that are not very water
soluble may require use of a very-large-capacity vessel
(up to 2000 ml) to observe significant dissolution. Sink
conditions is a term referring to an excess volume of
medium that allows the solid drug to continuously
dissolve. If the drug solution becomes saturated, no
further net drug dissolution will take place. According to
the USP, the quantity of medium used should be not less
than three times that required to form a saturated solution
of the drug substance.

Biopharmaceutics

Which medium is best is a matter of considerable

controversy. The preferred dissolution medium in USP
dissolution tests is deaerated water or if substantiated by
the solubility characteristics of the drug or formulation, a
buffered aqueous solution (typically pH 4-8) or dilute
HCl may be used. The significance of dearation of the
medium should be determined. Various investigators have
used 0.1 N HCl, 0.01 N HCl, phosphate buffer, simulated
gastric juice, water, and simulated intestinal juice,
depending on the nature of the drug product and the
location in the GI tract where the drug is expected to
dissolve. No single apparatus and test can be used for all
drug products. Each drug product must be tested
individually with the dissolution test that best correlates
to in vivo bioavailability.
The dissolution test usually states that a certain
percentage of the labeled amount of drug in the drug
product must dissolve within a specified period of time. In
practice, the absolute amount of drug in the drug product
may vary from tablet to tablet. Therefore, a number of
tablets from each lot are usually tested to get a
representative dissolution rate for the product. The USP
provides several official (compendia) methods for carrying
out dissolution tests of tablets, capsules and other special
products such as transdermal preparations. The selection
of a particular method for a drug is usually specified in the
monograph for a particular drug product.

BIOAVAILABILITY
BlQEQUWALE NCE
Bioavailability and bioequivalence may be determined
directly using plasma drug concentration vs. time profiles,
urinary drug excretion studies, measurements of an acute
pharmacologic effect, clinical studies, or in vitro studies.
Bioavailability studies are performed for both approved
active drug ingredients or therapeutic moieties not yet
approved for marketing by the FDA. New formulations of
active drug ingredients or therapeutic moieties must be
approved, prior to marketing, by the FDA. In approving a
drug product for marketing, the FDA must ensure that the
drug product is safe and effective for its labeled
indications for use. To ensure that the drug product
meets all applicable standards of identity, strength, quality,
and purity, the FDA requires bioavailability/pharmacokinetic studies and where necessary bioequivalence studies
for all drug products.
For unmarketed drugs which do not have full New
Drug Application (NDA) approval by the FDA, in vivo
bioavailability studies must be performed on the

97

drug formulation proposed for marketing. Essential

pharmacokinetic parameters of the active drug ingredient
or therapeutic moiety is also characterized. Essential
pharmacokinetic parameters include the rate and extent of
systemic absorption, elimination half-life, and rates of
excretion and metabolism should be established after
single- and multiple-dose administration. Data from these
in vivo bioavailability studies are important to establish
recommended dosage regimens and to support drug
labeling.
In vivo bioavailability studies are performed also for
new formulations of active drug ingredients or therapeutic
moieties that have full NDA approval and are approved for
marketing. The purpose of these studies is to determine the
bioavailability and characterize the pharmacokinetics of
the new formulation, new dosage form, or new salt or ester
relative to a reference formulation. After the bioavailability and essential pharmacokinetic parameters of the
active ingredient or therapeutic moiety are established,
dosage regimens may be recommended in support of drug
labeling.

Bioequivalent drug products are pharmaceutical equivalents whose bioavailability (i.e., rate and extent of
systemic drug absorption) does not show a significant
difference when administered at the same molar dose of
the therapeutic moiety under similar experimental
conditions, either single or multiple dose. Some pharmaceutical equivalents or may be equivalent in the extent of
their absorption but not in their rate of absorption and yet
may be considered bioequivalent because such differences
in the rate of absorption are intentional and are reflected in
the labeling, are not essential to the attainment of effective
body drug concentrations on chronic use, or are considered
medically insignificant for the particular drug product
studied [21 CFR 320.l(e)].

A generic drug product is considered bioequivalent to

the reference listed drug product (generally the currently
marketed, brand-name product with a full (NDA)
approved by the FDA) if both products are pharmaceutical equivalents and its rate and extent of systemic drug
absorption (bioavailability) do not show a statistically
significant difference when administered in the same
dose of the active ingredient, in the same chemical form,
in a similar dosage form, by the same route of
administration, and under the same experimental
conditions.

Biopharmaceutics

98

Pharmaceutical equivalents are drug products that

contain the same therapeutically active drug ingredient(s),
same salt, ester, or chemical form; are of the same dosage
form; and are identical in strength and concentration and
route of administration. Pharmaceutical equivalents may
differ in characteristics such as shape. scoring configuration. release mechanisms, packaging, and excipients
(including colors, flavoring, preservatives).
Therapeutic equivalent drug products are pharmaceutical equivalents that can be expected to have the same
clinical effect and safety profile when administered to
patients under the same conditions specified in the
labeling. Therapeutic equivalent drug products have the
following criteria: 1) The products are safe and effective;
2 ) The products are pharmaceutical equivalents containing the same active drug ingredient in the same dosage
form, given by the same route of administration, meet
compendia or other applicable standards of strength,
quality, purity, and identity and meet an acceptable in
vitro standard; 3) The drug products are bioequivalent in
that they do not present a known potential problem and
are shown to meet an appropriate bioequivalence
standard: 4) The drug products are adequately labeled;
5) The drug products are manufactured in compliance
with current good manufacturing practice (GMP)
regulations.
The generic drug product requires an abbreviated new
drug application (ANDA) for approval by the FDA and
may be marketed after patent expiration of the reference
listed drug product. The generic drug product must be a
therapeutic equivalent to the Reference drug product but
may differ in certain characteristics including shape,
scoring configuration, packaging, and excipients (includes
colors, flavors, preservatives. expiration date, and minor
aspects of labeling).
Pharmaceutical alternatives are drug products that
contain same therapeutic moiety but are different salts,
esters or complexes (e.g., tetracycline hydrochloride
versus tetracycline phosphate) or are different dosage
forms (e.g., tablet versus capsule: immediate release
dosage form versus controlled release dosage form) or
strengths.
In summary, clinical studies are useful in determining the safety and efficacy of the drug product.
Bioavailability studies are used to define the affect of
changes in the physic0 chemical properties of the drug
substance and the affect of the drug product (dosage
form) on the pharmacokinetics of the drug; whereas,
bioequivalence studies are used to compare the
bioavailability of the same drug (same salt or ester)
from various drug products. If the drug products are
bioequivalent and therapeutically equivalent, then the

clinical efficacy and safety profile of these drug

products are assumed to be similar and may be
substituted for each other.

MEASURE OF

The best measure of a drug products performance is to

give the drug product to human volunteers or patients and
then determine the in vivo bioavailability of the drug using
a pharmacokinetic or clinical study. For some well
characterized drug products and for certain drug products
where bioavailability is self-evident (e.g., sterile solutions
for injection), in vivo bioavailability studies may be
unnecessary. In these cases, the performance of the drug
product in vitro is used as a surrogate to predict the in vivo
drug bioavailability. Because these products have
predictable in vivo performance as judged by the in vitro
characterization of the drug and drug product, the FDA
may waive the requirement for performing an in vivo
bioavailability study (Table 8).

Drug Products for w ich BioavailabiIity

Drug bioavailability from a true solution is generally
considered self-evident. Thus, sterile solutions, lyophilized powders for reconstitution, opthalmic solutions do
not need bioequivalence studies but still must be
manufactured according to current GMPs. However,
highly viscous solutions may have bioavailability
problems due to slow diffusion of the active drug.

In Vitro-in Vivo orrelation ( I V I V ~ )

In vitro bioavailability data may be used to predict the
performance of a dosage provided that the dissolution
method selected is appropriate for the solid oral dosage
form and prior information has been collected showing
that the dissolution method will result in optimum drug
absorption from the drug product. In general, IVIVC is
best for well absorbed drugs for which the dissolution
rate is the rate-limiting step. Some drugs are poorly
absorbed and dissolution is not predictive of absorption
(1). The objectives of IVIVC are to use rate of
dissolution as a discriminating (i.e., sensitive to changes
in formulation or manufacturing process), as an aid in
setting dissolution specifications. When properly
applied, IVIVC may be used to facilitate the evaluation

99

Biopharmaceutics

Table 8

Examples of drug products for which in vivo bioavailability studies may be waived

Condition

Example

Comment

Drug products for which

bioavailability is self-evident

Drug solution (e.g., parented

ophthalmic, oral solutions)

Drug bioavailability from a true solution is

considered self-evident. However, highly viscous
solutions may have bioavailability problems.

In vivo-in vitro correlation

Modified release drug products

The dissolution of the drug from the drug product

in vitro must be highly correlated to the in vivo
bioavailability of the drug.

Biopharmaceutic classification
(BCS) system

Immediate release solid oral

drug products

Drug must be a highly soluble and highly

permeable substance that is in a rapidly
dissolving dosage form.

Biowaiver

Drug product containing a

lower dose strength

Drug product is in the same dosage form, but

lower strength and is proportionally similar in
its active and inactive ingredients.

(IVIVC)

of drug products with manufacturing changes including

minor changes in formulation, equipment, process,
manufacturing site, and batch size. (see section on
SUPAC) (2, 3, 10).
Three levels of IVIVC are generally recognized by
the FDA (10). Level A correlation is usually estimated
by deconvolution followed by comparison of the
fraction of drug absorbed to the fraction of drug
dissolved. A correlation of this type is the highest level
of correlation and best predictor of bioavailability from
the dosage form. A Level A correlation is generally
linear and represents a point-to-point relationship
between in vitro dissolution rate and the in vivo input
rate. The Level A correlation should predict the entire in
vivo time course from the in vitro dissolution data.
Level B correlation utilizes the principles of statistical
moment analysis, Various dissolution IVIVC methods
were discussed by Shargel and Yu in 1985, 1993, 1999
(1). The mean in vitro dissolution time is compared to
either the mean residence time or the mean in vivo
dissolution time. Level B correlation, like Level A
correlation, uses all of the in vitro and in vivo data but
is not considered to be a point-to-point correlation and
does not uniquely reflect the actual in vivo plasma level
curve, since several different in vivo plasma level-time
curves will produce similar residence times. A Level C
correlation is the weakest IVIVC and establishes a
single point relationship between a dissolution parameter
(e.g., time for 50% of drug to dissolve, or percent drug
dissolved in two hours, etc.) and a pharmacokinetic
parameter (e.g., AUC, Cmax, Tmax). Level C
correlation does not reflect the complete shape of the
plasma drug concentration-time curve of dissolution
profile.

B I O P H A ~ M A C ~ ~ TC
I CLSA ~ ~ ~ F I C A ~ I O N
SYSTEM (BCS)
The FDA may waive the requirement for performing an in
vivo bioavailability or bioequivalence study for certain
immediate release solid oral drug products that meets very
specific criteria, namely, the permeability, solubility, and
dissolution of the drug. These characteristics include the in
vitro dissolution of the drug product in various media, drug
permeability information, and assuming ideal behavior of
the drug product, drug dissolution and absorption in the GI
tract. For regulatory purpose, drugs are classified
according to BCS in accordance the solubility, permeability and dissolution characteristics of the drug (FDA
Draft Guidance for Industry, January, 1999, see FDA
website for guidance) (1 1). Based on drug solubility and
permeability, Amidon et al. (10, 12) recommended the
following BCS in 1995 (Table 9).
This classification can be used as a basis for setting in
vitro dissolution specifications and can also provide a basis
for predicting the likelihood of achieving a successful in
IVIVC. The solubility of a drug is determined by
dissolving the highest unit dose of the drug in 250 ml of
buffer adjusted between pH 1.0 and 8.0. A drug substance
is considered highly soluble when the dose/solubility
volume of solution are less than or equal to 250 ml. Highpermeability drugs are generally those with an extent of
absorption that is greater than 90%.

An objective of the BCS approach is to determine the

equilibrium solubility of a drug under approximate

Biopharmaceutics

100

Table 9

Biopharmaceutics classification system (BCS)

Condition

Comments

Solubility

A drug substance is considered highly soluble when the highest dose strength is soluble in 250 ml or less of water over
a pH range of 1-8.

Dissolution

An immediate release (IR) drug product is considered rapidly dissolving when not less than 85% of the label amount
of the drug substance dissolves within 30 min using the USP apparatus I at 100 rpm (or apparatus I1 at 50 rpm) in a
volume of 900 ml or less.'

Permeability

A drug substance is considered highly permeable when the extent of absorption in humans is to be >90% of an

administered dose based on mass balance determination.

"Media include: acidic media (e.g., 0.1 N HCI) or simulated gastric fluid, USP without enzymes, pH 4.5 buffer and pH 6.8 buffer of simulated intestinal
fluid, USP without enzymes (From FDA Draft Guidance, Jan, 1999.)

physiological conditions. For this purpose, determination

of pH-solubility profiles over a pH range of 1-8 is
suggested. Preferably eight or more pH conditions should
be evaluated. Buffers that react with the drug should not be
used. An acid 0s base titration method can also be used for
determining drug solubility. The solubility class is
determined by calculating what volume of an aqueous
media is sufficient to dissolve the highest anticipated dose
strength. A drug substance is considered highly soluble
when the highest dose strength is soluble in 250 ml or less
of aqueous media over the pH range of 1-8. The volume
estimate of 250 ml is derived from typical bioequivalence
study protocols that prescribe administration of a drug
product to fasting human volunteers with a glass (8 ounces)
of water.
Solution stability of a test drug in selected buffers (or
pH conditions) should be documented using a validated
stability-indicating assay. Data collected on both pHsolubility and pH-stability should be submitted in the
biowaiver application along with information on the
ionization characteristics, such as pKa(s), of a drug.

Table 10

ermeability Glass
Studies of the extent of absorption in humans, or
intestinal permeability methods, can be used to
determine the permeability class membership of a
drug. To be classified as highly permeable, a test drug
should have an extent of absorption >90% in humans.
Supportive information on permeability characteristics
of the drug substance should also be derived from its
physical-chemical properties (e.g., octano1:water partition coefficient).
Some methods to determine the permeability of a drug
from the GI tract include 1) in vivo intestinal perfusion
studies in humans, 2 ) in vivo or in situ intestinal perfusion
studies in animals, 3) in vitro permeation experiments
using excised human or animal intestinal tissues, and 4) in
vitro permeation experiments acsoss a monolayer of
cultured human intestinal cells. When using these
methods, the experimental permeability data should
correlate with the known extent-of-absorption data in
humans.

Postapproval change levels

Change level

Example

Comment

Level 1

Deletion or partial deletion of

an ingredient to affect the color
or flavor of the drug product

Level 1 changes are those that are unlikely to have any detectable
impact on formulation quality and performance.

Level 2

Quantitative change in excipients

greater that allowed in a Level 1 change.

Level 2 changes are those that could have a significant impact on

formulation quality and performance

Level 3

Qualitative change in excipients

Level 3 changes are those that are likely to have a significant impact
on formulation quality and performance. A Level 3 change may
require in vivo bioequivalence testing.

Biopharmaceutics

101

issolutio
The dissolution class is based on the in vitro dissolution
rate of an immediate release drug product under specified
test conditions and is intenended to indicate rapid in vivo
dissolution in relation to the average rate of gastric
emptying in humans under fasting conditions. An
immediate release drug product is considered rapidly
dissolving when not less than 85% of the label amount of
drug substance dissolves within 30 min using the USP
apparatus I at 100 rpm or apparatus 11 at 50 rpm in a
voluume of 900 ml or less in each of the following
media 1) acidic media such as 0.1 N HC1 or Simulated
Gastric Fluid USP without enzymes; 2) a pH 4.5 buffer;
and 3) a pH 6.8 buffer or Simulated Intestinal Fluid USP
without enzymes.

the FDA developed (2, 3, 5 , 3, 10, 3, 12-17) a series of

guidances for the industry that discuss scale-up and
postapproval changes, generally termed, SUPAC guidances (11). The FDA SUPAC guidances are for
manufacturers of approved drug products who want to
change 1) a component and composition of the drug
product; 2) the batch size; 3) the manufacturing site; 4) the
manufacturing process or equipment; and/or 5 ) packaging.
These guidances describe various levels of postapproval
changes according to whether the change is likely to
impact on the quality and performance of the drug product.
The level of change as classified by the FDA as to the
likelihood that a change in the drug product might affect
the quality of the product (Table 10).

FER

In addition to routine quality control tests, comparative

dissolution tests have been used to waive bioequivalence
requirements (biowaivers) for lower strengths of a dosage
form. The drug products containing the lower dose
strengths should be compositionally proportional or
qualitatively the same as the higher dose strengths and
have the same release mechanism. For biowaivers, a
dissolution profile should be generated and evaluated
using one of the methods described under Section V in this
guidance, Dissolution Profile Comparisons. Biowaivers
are generally provided for multiple strengths after
approval of a bioequivalence study performed on one
strength, using the following criteria: For multiple
strengths of IR products with linear kinetics, the
bioequivalence study may be performed at the highest
strength and waivers of in vivo studies may be granted on
lower strengths, based on an adequate dissolution test,
provided the lower strengths are proportionately similar in
composition [21 CFR 320.22(d)(2)]. Similar may also be
interpreted to mean that the different strengths of the
products are within the scope of changes permitted under
the category Components and Composition, discussed in
the SUPAC-IR guidance.

After a drug product is approved for marketing by the

FDA, the manufacturer may want to make a manufacturing change. The pharmaceutical industry, academia and

I . Shargel, L.; Yu, A.B.C. Applied Biopharrnaceutics and

Pharmacokinetics; McGraw-Hill Medical Publishing:
1999.
2. SUPAC-MR: Modified Release Solid Oral Dosage Forms;
Scale-Up and Post-Approval Changes: Chemistry, Manufacturing and Controls, In Vitro Dissolution Testing. and
In Vivo Bioequivalence Documentation, FDA, Guidance
for Industry, Sept. 1997.
3. Waiver of In Vivo Bioavailability and Bioequivalence
Studies for Immediate Release Solid Oral Dosage Forms
Containing Certain Active MoietiedActive Ingredients
Based on a Biopharmaceutics Classification System, FDA
Draft Guidance for Industry, Jan. 1999.
4. Skelly, J.P.; Shah, V.P.; Konecny, J.J.; Everett, R.L.;
McCullouen, 5 . ; Noorizadeh, A.C. Report of the Workshop
on CR Dosage Forms: Issues and Controversies. Pharmaceutical Research 1987, 4 (l),75-78.
5. Shah, V.P.; Konecny, J.J.; Everett, R.L.; McCullouen, 5 . ;
Noorizadeh, A.C.; Shah, V.P. In Vitro Dissolution Profile
of Water Insoluble Drug Dosage Forms in the Presence of
Surfactants. Pharmaceutical Research 1989, 6, 612-618.
6. Moore, J.W.; Flanner, H.H. Mathematical Comparison of
Dissolution Profiles. Pharmaceutical Technology 1996,
20 ( 6 ) , 64-74.
7. Hendeles, L.; Weinberger, M.; Milavetz, G.; Hill, M.;
Vaughan, L. Food Induced Dumping from Once-A-Day
Theophylline Product as Cause of Theophylline Toxicity.
Chest 1985, 87,758-785.
8. Allen, P.V.; Rahn, P.D.; Sarapu, A.C.; Vandewielen, A.J.
Physical Characteristics of Erythromycin Anhydrate and
Dihydrate Crystalline Solids. J. Pharm. Sci. 1978, 67,
1087 - 1093.
9. Aguiar, A.J.; Krc, J.; Kinkel, A.W.; Samyn, J.C. Effect of
Polymorphism on the Absorption of Chloramphenical
from Chloramphenical Palmitate. J. Pharm. Sci. 1967, 56,
847- 853.
10. SUPAC-IR Immediate Release Solid Oral Dosage Forms.
Scale-up and Post-Approval Changes: Chemistry, Manufacturing and Controls, In Vitro Dissolution Testing, and

Biopharmaeeutics

102

I 1.

12.

13.

14.

15.

In Vivo Bioequivalence Documentation, FDA Guidance for

Industry, Nov. 1995.
FDA Regulatory Guidances FDA Website for Kcgulatory
(iuidances. www.fda.gov/ccler/guidance/indes.htm).
Amidon, G.L.; Ixnncrnas, H.; Shah, V.P.; Crison, J.R. A
Theoretical Basis For a Biopharmaceutic Drug Classification: The Correlation of I n Vitro Drug Product
Dissolution and In Vivo Bioavailability. Pharniaceutical
Research 1995, 12, 413-420.
Skelly, J.P.; Amidon. G.L.; Barr, W.H.; Benet, L.Z.;
Carter, J.E.; Robinson, J.R.; Shah, V.P.; Yacobi, A. InVitro
and In Vivo Testing and Correlation for Oral Controlled/
Modified-Release Dosage Forms. Pharmaceutical Research
1990, 7, 975-982.
In Vitro-In Vivo Correlation for Estcnded Release Oral
Dosage Forms, Pharmacopeial Forum Stimuli Article.
United States Pharmacopeial Convention. Inc.: July 1988;
4160-4 161.
In Vitro In Vivo Evaluation of Dosage Forms, U.S.P.
XXIV< I088> United States Pharmacopeial Convention,
Inc. 2051-2056.

16. Shah, V.P.; Skelly, J.P.; Barr, W.H.: Malinowski, H.;

Amidon, G.H. Scale-up of Controlled Release Products Preliminary Considerations. Pharmaceutical Technology
1992, I6 ( 5 ) , 35-40.
17. Skelly, J.P. Rcport of Workshop on In Vitro and In Vivo
Testing and Correlation for Oral Controlled/ModifiedRelease Dosage Forms. Journal of Pharmaceutical Sciences
1990, 79 (9), 849-854.
18. Cadwallader, D.E. Biophnrmnceutics rind D rug Interactions; Raven Press: New York; 1983.
19. Cibaldi, M. Biopham~acruticsand Cinical Pharmacokinetics; Lea & Febiger: Philadelphia, 1984.
20. Cibaldi, M.; Perrier, D. Pharmacokinetirs; Marcel Dekker,
Inc.: New York, 1982.
21. McGinity, J.W.; Stavchansky, S.A.; Martin, A . Bioavailability in Tablet Technology. Pharmacrutical Dosage
Forms: Tablets; Lieberman, H.A., Lachman, L., Eds.;
Marcel Dckker, Inc.: New York, 1981; 2.
22. Rowland, M.; Tozer, T.N. Clinical Pliavmacokinelics.
Concepts and Applications; Lea & Febiger: Philadelphia,
1995.

PROFESSIONAL OKGANIZATIONS

University of Mississippi, Univer.5ity, Mississippi, U.S.A.

Council on Credentialing in Pharmacy, Washington, D.C., U.S.A.

INT

The Board of Pharmaceutical Specialties (BPS) was

established in 1976 under the auspices of the American
Pharmaceutical Association (APhA). The overriding
concern of BPS is to ensure that the public receives the
highest possible quality pharmacy services, contributing
toward outcomes that improve a patients quality of life.
The BPS has four primary responsibilities:
* To recognize specialties in pharmacy practice.
* To set standards for certification and recertification.
0
To objectively evaluate individuals seeking certification and recertification.
* To serve as a source of information and coordinating
agency for pharmacy specialties.

The BPS is located at 2215 Con\titution Avenue, NW,

Washington, D.C. 20037-2985, phone: (202) 429-7591 ;
fax: (202) 429-6304; www.bpsweb.org.

OVE~VI
Certification is a voluntary process by which a practitioners education, experience, knowledge, and skills are
confirmed by ones profession as meeting or surpassing a
standard beyond that required for licensure. The standards
and processes for certification (unlike those for licensure)
arc established by a professional, nongovernmental agency. RPS certification is at the specialty level and signifies
that an individual has met a national professional standard
and dcmonstrated mastery of a body of knowledge, skills,
and abilities in an advanced levcl in a specialized area
of practice.
Today, BPS functions as an agency of APhA with its
own governing Board structure. The board is composed

Em:).cloprdia of Clinical P Iiurmacy

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of six pharmacist members, two health care practitioners

outside of pharmacy, and one public member. The chair
of each Specialty Council and the BPS Executivc Director serve as nonvoting members of the Board. The
Executive Director of BPS is Richard J. Bertin, Ph.D.,
R.Ph. and the current Chair of BPS is Rogcr W.
Anderson, R.Ph., DrPH, who is Director of Pharmacy
at M.D. Anderson Cancer Center.
To date, five specialties have been recognized by
BPS: 1) nuclear pharmacy; 2) nutrition support pharmacy; 3) oncology pharmacy; 4) pharmacotherapy; and
5) psychiatric pharmacy. As of August, 2002, 34 14 pharmacists are certified as specialists in one or morc of these
specialties. Added Qualification is a process for providing recognition of pharmacists with further training
and experience in areas of concentration within an
existing specialty.

MISSION AND OBJECTIVE

The mission of BPS was refined in 1997 and is reviewed
by the Board semiannually. The mission is to improve
public health through recognition and promotion of
specialized training, knowledge, and skills in pharmacy
and certification of pharmacist specialists. The organization achieves its mission through accomplishment of six
strategic objectives including 1) providing leadership for
the profession of pharmacy in the discussion, evolution,
direction, and recognition of specialties in pharmacy; 2)
establishing the standards for identification and recognition of specialties in consultation with the profession; 3)
establishing standards of training, knowledge, and skills
as the basis for ccrtification of individuals; 4) developing
and administering objective and valid means to evaluatc
the knowledge and skills of pharmacist specialists; 5)
evaluating areas of specialization for their value and

103

104

viability; and 6) communicating the value of specialization and specialty certification in pharmacy.

adventure\ in a treatment area where novel and expcrimental drug therapies arc lrcquently employed.

BPS has recognized five spccialty practice areas. They arc

I ) nuclear pharmacy (1978); 2) nutrition support pharmacy (1 988); 3) pharmacothcrapy (1988); 4) psychiatric
pharmacy (1992); and 5) oncology pharmacy (1 996).
Nuclear pharmacy seeks to improve and promotc public hcalth through the safe and effectivc L I S of
~ radioactive
drugs for diagnosis and therapy. A nuclear pharmacist, as
a member of the nuclear medicine team, specializes in
procurcmcnt, compounding, quality assurancc, dispensing, distribution, and developmcnt of radiopharmaceuticals. In addition, thc nuclear pharmacist monitors paticnt
outcomes and providcs information and consultation rcgarding hcalth and safety issues.
Nutrition support pharmacy addrcsscs the care of patients receiving specialized parenteral or enteral nutrition.
The nutrition support pharmacist is responsible for promoting restoration and maintenance of optimal nutritional
status and designing and modifying treatment in accordance with paticnt needs. These specialists havc rcsponsibility for direct patient care and often function as members of niultidisciplinary nutrition support teams.
Pharmacotherapy is thc specialty responsible for ensuring the safe, appropriate, and economical usc of drugs
in paticnt carc. The pharinacotherapy specialist has
responsibility for dircct patient care and often functions
as a member of a multidisciplinary treatment team. Thcsc
spccialists may conduct clinical research and arc frcqucntly primary sources of drug information for other health
care professional s.
Psychiatric pharmacy addresses the pharmaceutical
care of paticnts with psychiatric disorders. As a mcmbcr
oP a multidisciplinary treatment tcam, thc psychiatric
pharmacist specialist is often responsible for optimizing
drug treatment and paticnt care by conducting patient
asscssmcnts; rccommending appropriate treatment plans;
monitoring patient response; and preventing, identifying,
and correcting drug-relatcd problems.
Oncology pharmacy addrcsscs the pharmaceutical care
of patients with canccr. The oncology pharmacist specialist promotes optimal care of patients with various malignant diseases and their complications. These specialists
are closely involvcd in recognition, management, and
prevention of uniquc morbidities associated with cancer
and canccr trcatmcnt; recognition of the balance bctwccn
improved survival and quality of lifc as primary outcome
indicators; and provision of safeguards against drug mis-

Added Qualifications is the mechanism used by BPS to

recognize further differentiation within a specialty which
thc Board has already recognized. This distinction may be
granted to a BPS-certified specialist on the basis of a
structured portfolio rcvicw process, administered by the
Specialty Council responsiblc for the specialty. Thc first
petition for Added Qualifications was i n Infectious
Diseases and was approved by the Pharmacotherapy
Spcciaity Council and BPS in 1999. The first candidates
were conferred the Added Qualifications in Infectious
Diseases crcdcntial in 2000. A petition for Added
Qualifications in Cardiology was approved in 2000, and
the first candidates were conferred the .Added Qualifications in Cardiology Pharmacotherapy credcntial in 200 1.

When a group of interested pharmacists wishes to have a

ncw spccialty considered for recognition by the BPS, they
submit a petition to the Board. The petition is evaluated
against seven criteria: 1) need of the profession and the
public for specifically traincd practitioncrs in thc spccialty
practice area to fulfill the responsibilities of the profession
in improving the health and welfare of the public; 2) clear,
significant demand for thc spccialty by the public and
health carc system; 3) presence of a reasonable number of
pharmacist specialists practicing in and devoting significant time in the specialty area; 4) spccialicd knowledge
of pharmaceutical sciences required by thosc practicing in
the specialty arca; 5) spccializcd functions provided by
pharmacists in the specialty practice area that require
education and training beyond thc basic level attained by
licensed pharmacists; 6) education and training in the
specialty arca provided by pharmacy colleges and other
organizations; and 7) transmission of knowledge in the
specialty practice area occurring through books, journals,
symposia, professional meetings, and othcr media.
After a new specialty is recognized by BPS, a Specialty Council of contcnt cxpcrts is appointed to work
with the RPS and a professional testing firm to develop a
psychometrically sound and legally defensible certification process. Thc Spccialty Council is composed of six
pharmacists practicing in the specialty area and three
othcr pharmacists. Certification examinations consisting
of 200 multiple choice questions are administered an-

Board of ~ ~ ~ r ~ ~Specialties
c ~ u t i c ~ ~ ~

nually at designated sites throughout the United States

and in other countries. Each BPS-certified specialist must
recertify every scven years. Approved professional devclopment programs are availablc as an alternative to
sitting for a 100-item recertification cxamination in nuclear pharmacy and pharmacotherapy. BPS continually
evaluates and updates its certification and recertification
processes. Approximately every five years, a new role
delincation study is conducted for each specialty, and
cxainination specifications are modified accordingly.

Spccialty certification in pharmacy olfers numerous potential benefits of significant value to patients, other health
professionals, employers. health care systems, and the
public. Specialty certilication denotes that specialists are
highly trained and skilled and havc demonstrated the
ability to identify, resolve, and prevent drug therapy problems. They havc taken the initiative to seek additional
education and expcricnce in a spccialized pharmacy field
and exhibit a high lcvcl of comtnitmcnt to patients and thc
profession. Certified pharmacist specialists function as
valued members of treatment tcams, optimizing and individualizing drug therapy. Employers can feel assurcd
that the knowledge and skills of certified pharmacist specialists have been testcd through a rigorous, objectivc, and
peer-determined process.
Ccrtification also provides a personal reward for pharmacist specialists. Specialty certification communicates
to others that thc specialists educational and practice
accomplishments differentiate the specialist from colleagues. Many specialists feel that thcy have a competitive edge in applying for positions, and some have received reimburscment from third-party payers, because
their skills and knowledge have been validated through

105

certification. Sornc pharmacist specialists have also reported increased salaries or one-time bonuses upon attaining BPS certification.
BPS certification has been formally recognized by the
American Association of Colleges of Pharmacy, the American College of Clinical Pharmacy, the American Pharmaceutical Association, the American Socicty for Parcntcral and Entcral Nutrition, the American Society of
Health-System Pharmacists, the Ordre des Pharinaciens du
Quebec, the Society of Infcctious Discases Pharmacists,
and the Society of Hospital Pharmacists of Australia.
BPS-certificd pharmacist specialists are recognized for
thcir advanced lcvcl of knowledge, skills, and achievcment by many government agencies and health care
organizations. The following are examples of specific
benefits that may bc realized by BPS-certified pharmacist
specialists:

U.S. Nuclear Rcgulatory Commission: specialists may

be licensed as Radiation Safety Officers and/or
recognized as Authorized Users.
U.S. Department of Defense: specialists may receive
bonus pay.
U.S. Department of Veterans Affairs: specialists may
serve at higher pay steps.
U.S. Public Health Scrvicc: specialists may receive
bonus pay.
Ncw Mexico State Board of Pharmacy: specialists may
apply for specified prescribing privileges.
At least seven Colleges of Pharmacy may exempt
BPS-certified specialists from some didactic courses in
postbaccalaureate or nontraditional Pharm.D. programs. Other Colleges award advanced placement on
an individual case basis and may recognize BPS
certification in this process.
Many other national, regional, or local employers of
RPS-certified pharmacists also recognize BPS ccrtificalion in thcir hiring, salary, or privileging policies.

PHARMACY PRACTICE ISSUES

anita

la

Hcnry Ford Health Syslem, Iletroit, Michigan, U.S.A.

The utilization of a bone marrow transplantation to treat

hematologic malignancies, solid tumors, genetic disorders, metabolic diseases, immune deficicncy disorders,
and bonc marrow failures has grown tremendously since
the first successful transplant in 1968. l f these diseases
are not treated aggrcssively, they can be fatal. The scriousncss of thcsc diseases is retlected in the intense care
providcd to the patient during and after a bonc marrow
transplant. Whether the patient receives an autologous,
syngeneic, or allogcneic bone marrow transplant, thc
patient needs to be followed very closely for the first
several weeks to several ycars (depending on the type
of bone marrow transplant and type of post-transplant
complications) by the bone marrow transplant team.
After an allogcncic bone marrow transplant, the patient
needs to be seen in clinic 1 to 3 days per week for physical
examinations, blood work, special microbiology testing,
and medication adjustments. Once a bone marrow transplant patient is deemed to be stable, their outpatient visits
will slowly decrease.
The medications used during a bone marrow transplant
and post- bone marrow transplant carry extensive toxicity
profiles and have numerous drug-drug/drug-food interactions, and the majority of medications arc expensive.
These characteristics in themselves justify the necessity
of a pharmacist to bc a key member of the bone marrow
transplant team.

Thc majority o f bone marrow transplant centers (espccially thosc pcrforming allogeneic bone marrow transplants) in the United Statcs have a pharmacist on the
team. Currently, there arc approximately 450 bone marrow transplant centers registered in 48 different countries
with thc National Marrow Donor Program."' In most
cases, thc pharmacist is employed by the Department of
Pharmacy with partial or completc financial support from
the Department of Medicine. With thc stringent criteria
106

developed for medical reimbursement by third-party

payers (i .e., health maintenance organizations, preferred
provider organizations, and mcdicaid/medicare), both the
Departments of Pharmacy and Medicine have a strong
interest in driving cost down. Since 11-37% of a bone
marrow transplant cost is attributed to pharmaceuticals,
the pharmacist plays a critical rolc in lowering the cost of
a bone marrow transplant via close medication monitoring.12' Similar to other clinical pharmacists, the bone
marrow transplant pharmacist needs to monitor all drugs
given to the patient Ior appropriate usage. However, the
majority of medications used by a bone marrow transplant
patient carry high levels of toxicities, narrow therapeutic
windows, and life-threatening results if mcdication doses
are forgotten or increased or decreased by thc patient,
thereby elevating the intensity of drug monitoring.
The bone marrow transplant team members primarily
consists of a specially trained hematologist/oncologist,
pharmacist, nurse practitioner/physician assistant, social
worker, dietitian and/or total parenteral nutrition (TPN)
personnel, and ? hematology/oncology medical fellow(s).
The team members rely heavily on each other to ensure
that appropriate, safe, and cost-effective care is given to
each patient. The pharmacist-nurse practitioncdphysistant relationship assists in combining physical
assessment findings with drug outcomes. The pharmacist-social worker relationship is necessary for discharge
planning to ensure medication affordability and appropriate home medication administration. The pharmacistdietitian/TPN personnel rclationship helps decrease
drug-food interactions with mealtime plan changes
and/or meal content changes and decrease cost by minimizing intravenous hyperalimentation usage. In some
institutions, the pharmacist plays a lead role in dietary
care, thereby negating the need for an additional dietary
personnel. The pharmacist~hematology/oncoIogy fellow relationship is primarily a teaching role for both
parties. Finally, a sound pharmacist-physician relationship needs to be developed for the physicians to entrust
patient care to a pharmacist. Once this bond has been
established, a pharmacist's knowledge can be used for
clinical advice on patient care, investigating innovative

Enc.yc.lope.din qr ('1inic.d Phnrrnucy

DOI: 10.108 l/E-ECP 120006224
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Bone Marrow Transplant Pharmacy Practice

options for patient care, and developing research protocols to advance patient care. Therefore, in addition to a
solid knowledge base in hematology-oncology, immunology, infectious diseases, fluid/electrolyte balance, and
pain management, it is imperative for a bone marrow
transplant pharmacist to possess excellent communication
and people skills.

107

Because the patients immune system is compromised

for several months to several years secondary to the slow
process of complete bone marrow recovery and/or longterm usage of immunosuppresives, the patient is vulnerable to numerous life-threatening infectious disease
processes. In addition, the allogeneic bone marrow transplant patient always carries a certain risk (highest per-

Table 1 Pharmacists responsibilities

Unstable patient

Stable patient

Adjust medication regimen(s) based on drug levels to

enhance efficacy and/or prevent toxicity.b

Adjust medication regimen(s) based on drug levels to

enhance efficacy and/or prevent toxicity.a.b

Monitor diug-drug and drug-food interactions to

prevent toxicity.

Monitor drug-drug and drug-food interactions to

prevent toxicity.

Educate the bone marrow transplant team about each

medications effect on the bone marrow.d

Educate the bone marrow transplant team about each

medications effect on the bone marrow.asd

Offer advice on antibiotic choice(s) based on microbiology

results, patients immunologic state (i.e., neutropenic,
type of underlying cancer), patients infectious disease history
(i.e., past infection(s), serology results), institutions
microorganism-drug susceptibility record, and institutions
microorganism resistance pattern.
Adjust fluids and electrolytes based on daily laboratory values
and medication changes.e
Pain management. Acute pain secondary to mucositis needs
persistent close monitoring and abrupt drug adjustments to
attain near complete pain control within 4-6 hours.

Pain management. Chronic pain secondary to chronic

GVHD needs close monitoring and drug adjustments to
attain near complete pain control within 24-48 hours.

Monitor patients for acute toxicities secondary to conditioning

regimen 2 immunosuppressive agents. In addition, offer advice on
preventive therapies for toxicities and treatment options for toxicities.

Monitor patients for chronic toxicities secondary to

conditioning regimen *immunosuppressive agents. In
addition, offer advice on preventive therapies for
toxicities and treatment options for toxicities.

Educate patient upon discharge on the importance of each

medication by clearly writing the brand name and generic name
of each medication, explaining the purpose of each medication,
the time(s) of day each medication should be self-administered, the
consequences of missing or doubling doses, and a contact name
(preferably the pharmacist) and phone number for use if further
questions arise at home.

Assure medication compliance by reviewing medication

calendar. Once the patients are stable, they are more apt
to develop their own regimens. These regimens may allow
medications to be dosed too close together or too close to
meal times, skip certain medications deemed unnecessary
by the patient, and/or add certain medications (i.e., natural
herbs, vitamins).

Conduct clinical research. Pharmacist-initiated research projects

arise frequently from day-to-day unresolvable issues. Pharmaceutical
industry-sponsored research projects are also available.f

Conduct outcome-based research. Because a pharmacist

closely monitors the bone marrow transplant patients
for a prolonged period of time, there is an abundance of
data available for outcome-based research.

aExamples include, cyclosporine, tacrolimus, aminoglycosides, vancomycin.

bThese tasks are performed at a lower intensity level than their counterparts.
Examples include, choice of antihypertensive agent to be used while on cyclosporine or tacrolimus, timing medication ingestion around meal times.
dAfter identifying medications that are detrimental to the bone marrow, offer options for treatment that have no effect or minimal effect on the bone
marrow.
eThe pharmacist has the key role in preventing fluid and electrolyte abnormalities from occurring secondary to medications and aggressively correcting
all fluid and electrolyte abnormalities.
Pharmacists need to be aggressive in indentifying projects and seek funding for the project^.'^' Pharmacists should strive to be the primary investigator or
coinvestigator on the projects.

108

centage if the donated bone marrow is from an unrelated individual without a 6/6 Human Lymphocyte
Antigen match) for developing acute and/or chronic
graft-versus-host disease (GVHD). If the patient develops GVHD, the immune system is even further compromised by not only the intense immunosuppressive
agents needed for treatment, but also by the GVHD
itself. Thus, an allogeneic bone marrow transplant patient may have numerous hospital readmissions for
treatment of infectious disease processes, aggressive
treatment, and close monitoring of moderate-to-severe
GVHD or bone marrow failure (i.e., tumor relapse, bone
marrow engraftment lost). The majority of patients are
at highest risk for readmission during the first 100 days
post-transplant. Bone marrow transplant recipients of
mismatched or unrelated donors require more intense
bone marrow immunosuppression for a longer period of
time than their counterparts who receive matched or
related bone marrow, thereby increasing their risk for
hospital readmissions for a period greater than 100 days.
Because the patients medical needs can change drastically from day to day, the pharmacist needs to stay
abreast of all new medication regimens required for
patient care. It is imperative that the pharmacist has a
good working relationship with the patient and patients
caregivers to ensure appropriate adherence to the evolving medication regimen.
Recently, there has been a surge of bone marrow
transplant centers shifting inpatient care to the outpatient
setting early in transplant (post bone marrow/peripheral
blood stem cell infusion). The incentive for this trend has
been to decrease the cost of bone marrow transplant and
improve the patients quality of life. Stringent, institutionspecific criteria have been developed for patients to be
outpatient bone marrow transplant candidates. The primary basis behind the criteria rely on the patient and a
dedicated caregiver to be attentive to all their medical
needs, including comprehension of appropriate medication administration guidelines. The patients are responsible for self-administration of scheduled and as needed
oral, subcutaneous, and intravenous medications. By
placing this level of responsibility on the patient and
caregiver, the patient can be overcome with anxiety. A
pharmacist plays a dominant role in alleviating any confusion or misunderstanding on medication self-administration. The bone marrow transplant pharmacist will
need to thoroughly educate both the patient and caregiver
on all the medications daily. Although the patient maybe
medically stable in the outpatient setting, the initial
amount of time the pharmacist needs to spend with the
patient is equivalent to a complicated hospitalized bone
marrow transplant patient.

Bone Marrow Transplant Pharmacy Practice

There is a definite need for both an inpatient and

outpatient bone marrow transplant pharmacist. Due to the
patients initial prolonged inpatient stay and high probability of multiple readmissions during the first several
months post-bone marrow transplant, the distinction between an inpatient and outpatient bone marrow transplant
pharmacist role becomes unclear. To help maintain continuity of care, usually one pharmacist (labeled as the
inpatient pharmacist) will manage a patients pharmaceutical needs both during the initial hospitalization and
during the first several months of outpatient care. Once a
patients ambulatory visits decrease to at least once every
2 weeks, the outpatient pharmacist will attend to the
patients medication needs. If the institution predominantly performs autologous bone marrow transplants or if
the number of bone marrow transplants (autologous
combined with allogeneic) performed is low, then one
pharmacist is sufficient to play both the inpatient and
outpatient role.
The type and level of care provided by the pharmacist
depends on the stability of the patients health (Table 1).
Generally, the patient is most unstable during the
transplant and for the first several months post-transplant.

The type of work a bone marrow transplant pharmacist

performs on a daily basis depends on the goal of the
employer. A pharmacist can be predominantly research
based or clinically based.

Most of the bone marrow transplant pharmacist positions

with research emphasis are tenure-tracked or tenured with
a teaching hospital. These pharmacists have minimal to
no direct patient care duties assigned to them. Pharmacists
are responsible for the following:

1. Developing research protocols

2. Applying for grants to fund the protocols
3. Screening and enrolling patients into study (when
applicable)
4. Developing/running various assays
5 . Publishing research results
6. Didactic, experiential university-based teaching
The majority of pharmacists will participate in
pharmacy doctoral or postdoctoral programs or develop
bone marrow transplant fellowships to attain reliable,

109

Bone Marrow Transplant Pharmacy Practice

hardworking assistance in the laboratory. In turn, the

students/fellows will be closely mentored by the pharmacist. This symbiotic relationship will allow both parties
to augment research productivity, increase the number
of publications, and attain larger funding sources.

Most of the bone marrow transplant pharmacist positions with clinical emphasis are nontenure-tracked.
The pharmacists primary job responsibilities revolve
around direct patient care. Pharmacists are responsible
for the following:

1. Reviewing patients laboratory bloodwork, microbiology results, and medication profiles on a

daily basis
2. Attending and actively participating in patient medical rounds and patient clinic visits
3. Reviewing medications used in bone marrow transplant patients for inpatient and outpatient formulary usage
4. Helping to standardize care by developing protocols and procedures for bone marrow transplant
medication utilization
5 . Publishing material related to bone marrow transplant patient care
Although a clinical pharmacists emphasis is on direct
patient care, many of the pharmacists do perform clinical
research, seek for grants or awards to fund their research
projects, publish research results, participate in university-based teaching (didactic k experiential), and assist in
mentoring pharmacy residents specializing in hematology-oncology. A clinical pharmacist is expected to remain abreast of the bone marrow transplant literature,
especially in the following areas: GVHD, veno-occlusive
disease, infectious disease processes, and chemotherapyradiation-related toxicities. In addition to the pharmacists clinical knowledge, the bone marrow transplant
team heavily relies on the pharmacist for their knowledge
of the practical aspects of pharmacy (i.e., compatibility
issues, ability to compound products, maximudminimum concentrations of intravenous medications, understanding of the institutions medication order entry and
medication delivery processes). The clinical bone marrow transplant pharmacists main goals are to provide
safe, therapeutic, and cost-effective care to each patient,
and to maintain continuity of patient care upon initial
hospital discharge.

HEALTH OUTCOME AND

Currently, there is no published literature documenting

health outcome or economic benefits provided by a
pharmacist to a bone marrow transplant patient. There are
several review articles analyzing the economics of bone
marrow transplant, peripheral blood stem cell transplant,
and outpatient-based tran~plant.[~.~-l
The articles refer to
various detailed cost-effective and cost-minimization
studies. Unfortunately, they do not breakdown the cost
analysis studies to note the impact a pharmacist has on the
total cost of a bone marrow transplant procedure. The
input provided by a pharmacist to the bone marrow
transplant team is substantial and necessary for a cancer
center to remain competitive and fiscally responsible.
There is a strong need for bone marrow transplant
pharmacists to generate outcome data and collectively or
individually publish the benefits of retaining a pharmacist
on the bone marrow transplant team.

NECESSARY TOOLWMATERIALS
Medline
Many of the complications encountered during a bone
marrow transplant have few (if any) standardized
treatment protocols developed. Therefore, pharmacists
need easy accessibility to a medline service during and
after patient rounds to provide valuable information to the
bone marrow transplant team in a timely manner. Although physicians may also perform their own research
on the topic of discussion, it is important for pharmacists
to critique and review the literature separately. This will
allow the pharmacist to

1. Evaluate various innovative treatment options.

2. Choose the best option that complies with the
hospital policies and procedures for drug attainment, drug compounding, and drug administration.
3. Resolve drug availablity issues (i.e., orphan drug
status, length of time to receive drug in hospital).
4. Present the options to the bone marrow transplant
physician in a timely manner.

Hematopoiesis Chart
The bone marrow transplant pharmacist needs to have a
sound understanding of the maturation of the hemato-

I10

Bone Marrow Transplant

poictic stem cell to form the three lineages. It is important to understand the rclevancc of immunomodulators
at each step of cell maturation. ecausc ex-vivo cytokines are very expensive and many of them carry high
toxicity profiles, it is important for a pharmacist to
know which stem cell maturation step(s) will be influcnccd by the cytokine(s).

Currently, there are no published documents providing

guidelines or consensus statements on how medications
should be administered during and following a bone
marrow transplant. There are numerous review articles
available on bone marrow transplant preparative regimens, prevention and treatment of graft versus host
disease, infectious disease topics related to bonc marrow transplant, and pain management. The chemothcrapy/radiothcrapy used as the preparative regimen for a
bone marrow transplant varies from center to center,
depending on the hematologists past experience with
thc various regimens, the patients eligibility for drug
study enrollment, the patients past chemotherapy/radiotherapy history, and the patients past medical history.
Thc medications and medication doses used to prevent
D and to treat other bone marrow transplant related complications is also dependent on the physicians preference, patients cligibility for drug study
enrollment, and patients medical history.

Ilnfortunately, a pharmacy conference/meeting specializing or subspecializing in bone marrow transplant

has not been identified. There is a rising interest in
forming a bone marrow transplant pharmacy network
group; perhaps modclcd after the infectious disease
pharmacy group (Society of Infectious Disease Pharmacy meet annually at their medical counterpart conference, Interscience Conference on Antimicrobial Agents
and Chemotherapy).
ACCP Oncology pm mainly targets the hematology/
oncology pharmacists and ACCP Transplant prn mainly
largets the solid organ transplant pharmacists. Thus,
bone marrow transplant pharmacist members of ACGP
arc not strongly committed to any particular ACCP
pm group.

I.

2.

3.

4.

5.

Thcrc are numerous bone marrow transplant web sites

available; however, they arc oncology center initiated to
increase patient relerral base or patient initiated to provide personal advice to other bone marrow transplant
patients. The networking opportunities available for bone
marrow transplant pharmacists are primarily in the following medical conferences/mcctings:

I . American Society of Hematology (ASH)

2. American Society of Clinical Oncology (ASCO)

6.

I.

http:/IIBMTK.org/sitemap/sitcmap/html
(acccsscd Scptcmber, 2000).
Bailey, E.M.; Pindolia, V.K. How to obtain funding for
clinical research. Am. J. Hosp. Pharm. 1994, 51, 2858~2860.
Weeks, F.M.; Yee, G.C.; Bartfield, A.A.; Wingard, J.R.
The true cost of bone marrow transplantation. Am. J. Med.
97, 314 (2), 101 112.
Waters, T.M.; Bcnnctt, C.L.; Pajeau, T.S.; Sobocinski,
K.A.; Klein, J.P.; Rowlings, PA.; Horowitx, M.M. Economic analyses of bone marrow and blood stem cell
transplantation for leukemias and lymphoma: What do we
know? Bone Marrow Transplant. 1998, 21, 641 650.
Bennett, C.L.; Waters, T.M.; Stinson, T.J.; Almagor, 0.;
Pavletic, Z.S.; Tarantolo, S.K.; Bishop, M.R. Valuing
clinical stratcgics early in development: A cost analyses of
allogeneic periphcral blood stem cell transplanlation. Bone
Marrow Transplant. 1999, 24, 555-560.
Rixzo, J.D.; Vogelsang, G.B.; Krumm, S.; Frink, B.; Mock,
V.; Bass, E.B. Outpatient-based bone marrow transplantation for hematologic malignancies: Cost savings or cost
shifting? J. Clin. Oncol. 1999; 17 (9), 281 1 2818.
Barr, K.; Furlong, W.; Henwood, J.; Feeny, D.; Wegener,
J.; Walker, 1.;Brain, M. Economic evaluation of allogeneic
hone marrow transplantation: A rudimentary model to
generate estimates for the tinicly formulation o f clinical
policy. J. Clin. Oncol. 1996, 14, 1413 - 1440.

PROFESSIONAL ORGANIZATIONS

aton
Univenity of Toronto, Toronlo, Onhrio, Canadi

I
The mission of the Canadian Hospital Pharmacy Residency Board is to establish and apply standards for
accreditation of pharmacy practice residency programs
and to promote excellence in hospital pharmacy residcncy
programs and practice. The key objectives are as follows:

1
2

To gain cxternal recognition dnd support tor phdrmacy residency program\

To provide \upport to residency program participants i n their role through educdtion, skill development and practice tools
To foster an environment that facilitates the growth
and development of ph'irmacy reiidency progrdinc

The Canadian Hospital Pharmacy Rcsidency Board was

established in the early 1960s. The assessmcnt of the residency training programs was done following review of
written documentation submitted to the Board. The onsite accreditation process and survcy did not begin until
the early 19XOs, however. At the present time, the Board
accredits residency training programs in pharmacy
practice. Currently, there are 30 programs in Canada
with 104 positions for prospective rcsidents. The Board is
not currently involvcd in thc accrcditation of specialty
programs or pharmacy technician training programs.

The current major initiatives consist o f

The Canadian Hospital Pharmacy Kesidency Board is organized under the auspices of Canadian Society of Hospital Pharmacists. The Board consists of seven members.
The terms of reference of the Board specifics that at least
one of the members be from a recognized Faculty of
Pharmacy. The membcrs of the Board are selected by the
Board itself and approved by CSHP Council. A chairperson and vice-chair are elected from the seven member
Board, with a term of two years for each of the executives.
The members themselves serve for two years, a term
which is renewable twice for a total of six ycars.
The Canadian Hospital Pharmacy Residency Board
currently conducts its work under thc auspices of the
Canadian Society of Hospital Pharmacists. As such, the
Board is provided administrative support from CSHP (at
1145 Hunt Club Road, Suite 350, Ottawa, Ontario, KIB
0V3; telephone 61 3-736-9733).

Enryrloprdia ($ Cliiiical Phcinnary

DOI: lO.IOXl/E-ECP120006286
Copyright C 2003 by Marcel Dekkcr, Inc. All rights reserved

I . Consistent with the four-year cycle for accreditation, to updatc the standards of the Board for 2002.
2. To promote thc use of the CHPRB-sponsored preceptor guidelines.
3. To evaluate the nccd or innovative specialty
practice standards and, in particular, those to be
used in an ambulatory setting.
4. To conduct a needs assessmcnt of residents who
havc becn in the residency training program over
the past threc years to determine future directions
of residency training in Canada.

w w w .cshp .ca

111

PROFESS I 0 NA L 0 RGAN IZATIO NS

sto
Canadian Pharmacists Association, Ottawa, Ontario, Canada

The Canadian Pharmaceutical Association (CPhA) was

founded in September 1907 as a national body for the
profession of pharmacy in Canada. Its involvement in
publishing began early in its history with the assumption
of responsibility for the Canadian Formulary in 1929.
The first edition of the Compendium of Pharmaceuticuls
and Speciulties (CPS) was published in 1960 and continues today, along with a number of other well-respected health care publications including Nonprescription
Drug Kejerence ,for Health Projessionals, Compendium
of Nonprescription Products, Therapeutic Choices, and
Herbs: Everyduy Rejerence ,for Health Professionals.
The latter is published jointly with the Canadian Medical Association.
Throughout the late 1980s and early 1990s, CPhA scope
of activities increased with staffing in the areas of professional development, research, and government and
public affairs.
In 1995, CPhA began to change its structure from an
organization representing provincial and national pharmacy organizations to an organization representing individual pharmacist members. This was followed in 1997
by a name change from Canadian Pharmaceutical Association to Canadian Pharmacists Association to better reflect the associations mandate.

of president, president-elect, past president, and three

vice presidents.
The executive dircctor, who is a nonvoting member
of the Executive Committee and Board, is responsible
for the management and control of the affairs of the
Association and general direction established by Board
policy. A staff o approximately 50 reports to the cxccutive dircctor.

The Canadian Pharmacists Association is the national

voluntary organization of pharmacists committcd to providing leadership for the profession of pharmacy.
The vision of CPhA is to establish the pharmacist as
the health care professional whose practice, based on
unique knowledge and skills, cnsurcs optimal patient outcomes. CPhA will achieve its vision by serving its members through:
Advocacy.
* Facilitation.
* Provision of knowledge.
0
Participation in partnerships.
0
Research and innovation.
Education.
0
Health promotion.
0

trate

CPhA is an organization of approximately 9000 individual members. Members directly elect members of the
Board or Directors to represent each province, pharmacy students, and thc three practice specialties of hospital pharmacy, industrial pharmacy, and academia. The
Board is responsible for managing the affairs of CPhA.
The Board clccts an Executive Committee comprised
112

CPhA operates according to its strategic plan developed

in 1999 and revised in 2001. The plan has five key result
areas:
1. To represent the interests of a majority of pharmacists and to create cohesiveness within the
profession on matters of practice, principle, and
policy.
Encyclopedia of Clinical Pharmacy
DOI: 10.1081iE-ECP120006202
Copyright 0 2003 by Marcel Dekker, Inc. All rights reserved.

113

Canadian Pharmacists Association/Association des Pharmaciens du Canada

2. To promote and facilitate the evolution of the

pharmacy profession toward an expanded role in
health care.
3. To foster public recognition of pharmacists as drug
experts and as members of the health care team.
4. To secure appropriate reimbursement for pharmacists professional services.
5 . To effectively analyze and respond to the impact
of advances in information technology on pharmacy practice.
6. To align resources to the key result areas.

CPhA has taken the leadership position in addressing

the shortage problem in the profession by initiating the
development of a proposal for a labor market study to
help pharmacy understand the current manpower
shortage and its causes and develop tools to forecast
future needs. Human Resources Development Canada
(HRDC) commissioned an initial phase of the study,
which is a literature search and key informant interviews to identify gaps in the available data. This
study, A Situational Analysis of Human Resource
Issues in the Pharmacy Profession in Canada, is available on the CPhA web site.] The next step is development of a proposal for funding from HRDC for a
comprehensive human resources study of the pharmacy
profession in Canada to develop the foundation required to properly manage current and future pharmacy
human resources.

Prescri

tho r ity

One of the key objectives of the strategic plan is a

move to acquire prescribing authority for pharmacists.
CPhA has developed a discussion paper to foster debate within the profession. The document has been
distributed to solicit pharmacists and other stakeholders input.

Privac

care until January 2002. With the passage of the

legislation, CPhA participated in a working group with
six national health provider and consumer associations
to examine the issue of privacy protection in Canada.
The report of the Privacy Working Group focuses on
the challenges of developing and implementing principles for privacy protection. lt highlights the lack of
consensus and the tension on this issue due to the disparate perspectives of the many stakeholders involved.
CPhA continues to seek effective remedies to the shorcomings in the legislation, including presentations to
federal officials.

It is recognized that pharmacists are spending an excessive amount of time dealing with claims reimbursement
with third-party payers. This is having a significant impact on working conditions, and administrative burdens
are proving an impediment to patient care. As a result,
CPhA joined forced with the Canadian Association of
Chain Drug Stores and the Ontario Pharmacists Association to sponsor a 2-day workshop to tackle these issues.
Priorities for action include a standardized drug benefit
card and PIN lists, patient awareness, benefit plan messages, and further collaboration with insurers and pharmacy software vendors.

har
tan
tan
Over the last decade, CPhA has been a leader in the
development of pharmacy communication standards.
CPhAs PECS Version 3.0 facilitates more than 98%
of the electronic pharmacy claims in Canada. PECS
Version 3.0 has undergone extensive revisions and now
is being integrated into a National E-Claims Standard
lnitiative (NeCST)[31 designed to address the current
need for a national electronic standard for health
claims information.

i~lation

CPhA was pivotal in securing an amendment to the

Personal Information Protection and Electronic Documents ActL2] which delayed its application to health

A major reengineering of the CPhA web site is underway.

This revitalized site will offer Web services to benefit our
members (e.g., electronic membership and order transactions, chat rooms, e-mentoring, e-broadcast).

I I4

Canadian Pharmacists AssociationlAssociation des Pharmaciens d~ Canada

In association with this initiative, an e-commerce advisory committee advises on e-commerce strategy and
assists with visualizing and developing enhancements to
CPhAs web site for member and nonmember pharmacists, other health care professionals, and consumers.

CPhAs annual meetings generally are held in May of

each year in major locations in Canada.

EF
CPhA, through its publishing program, provides pharmacists in every practice setting with accurate, current drug
information and resource materials. However, on-line
of our drug information presents new challcngc. Work is underway on the CPS so that this publication can be easily accessible Tor print and electronic
publishing. The CIS and our other publications are being
rcpurposed for use on new e-media platforms.

I.

ES

A Situational Analysis of Human Resource Issues i n the

Pharmacy Profession in Canada. http://www.cdnpharm.ca

(accessed Junc 25, 2001).

Personal Information Protection and Electronic Documents Act. http://www.privcom.gc.ca (accessed June 22,
2001).
3. National e-Claims Standard Initiative. http://www.cihi.ca/
eclaims/intro.shtml (accessed June 25, 200 I ).
2.

PROFESSIONAL DEVELOPMENT

University o f Mdryhnd, HJltiinore, Maryland, U.S.A.

INTR
Drug therapy plays a critical role in cmergency medical
care and, as a result, places the pharmacist in a position to
have a significant impact on potcntially life-saving thcrapeutic maneuvers. Pharmacists who practice in emcrgency medical carc scttings are oftcn called upon to
providc drug-related services and information without the
luxury of time to retrieve information from external
sources. This article reviews the role of pharmacy services i n both the cardiac arrest setting and in the provision of other crnergency medical scrvices in which
pharmacists play a central role.

pitals has been collected through questionnaires or surveys. Activities most frequently reported by pharmacists through such surveys are drug preparation, dosage
and infusion rate calculation, drug use documentation,
and thc provision of drug information; very few pharmacists administer artificial respiration or chest compression.12 Less frequently reported activities iiiclude
setting up or operating infusion dcvices and administering medications.
According to data from the National Clinical Pharmacy Services study from 1992 to 1998, approximately
30% of 950- 1600 hospitals surveyed had a pharmacist
as an active member of the team attending most
cardiac arrcsts when the CPR team pharmacist was in
the hospital.
Dcspite the significant percentage of
hospitals in which pharmacists arc members of the
cardiac arrest team, only 0.2%-0..3%1 of inpatients who
experienced a cardiac arrest receivcd resuscitation by a
team that included a pharmacist. This disparity may be
due to the fact that a CPR team pharmacist is not providing 24-hour, 7-day-per-week coverage, or that the
CPR team pharmacist was assigned to providc scrvice
only in a specific area of the hospital. The national
study also rcvealed that, of the hospitals with a pharmacist on the CPR team, approximately 65% routinely
document pharmacists involvement in patients medical
records. The average time cornmitinent for pharmacists
per arrest was 35 minutes. In the 1992 survey, this
amount of time per encounter was more than the avcrage amount of time for any other clinical scrvice
examined in the survey.
There is limited documentation of the value of pharmacists on cardiac arrest teams. What little data there are
tend to be anecdotal in nature. As far back as 1972, Elenbaas responded to a review of thc value of organized
cardiac arrest teams in hospitals by noting the obvious
absence of the inclusion of a pharmacist as a member of
the team.61 Given the extremely small number of actual
patient arrests in which pharmacists participate, it would
be difficult to accurately measure the actual or perceived
value of pharmacist participation. Based on the small

The spectrum of carc required for patients in cardiac

arrest ranges from providing basic life support (Cardiopulmonary resuscitation, or CPR) within or outside of
an organized health care setting, to evaluating and trcating complex cardiac arrhythmias in patients with multiple comorbidities receiving advanced cardiac life suphave bcen involved in the development
of drug-rclated health services designed to support the
care of such patients since the late 1960s. As scientific
and clinical outcome data has dramatically expanded
since thc 1960s and the efficacy of drug use in the cardiac arrest setting has been more critically evaluated,
potential roles for thc pharmacist have become more
obvious. In addition, as hospital accrediting agencies begin to address quality improvement issues in the cardiac
arrest setting, the evaluation and documentation of rational drug use will become a [actor in setting standards
of care.

ENT

AClST

The majority of information related to the activities of

pharmacists participating in cardiac arrest teams in hos-

Erryclopedia of Cliniwl Pliarnzucy

DOI: 10.108 I/E-ECP 120006320
Copyright C 2003 by Marccl Dckkcr, Inc. All rights rescrved

115

116

number of reports in the litcrature, the provision of drug

information seems to evoke the most comincnts rcgarding the value of pharmacist participation. Because the
role of physicians and nurses in the cardiac arrest setting has been so well establishcd compared with the role
that pharmacists currently fill and becausc thcrc arc
currently no standards established for pharmacists activities in this setting, the valuc of the pharmacist remains to
be measured.
A well-delineatcd support role for the pharmacist in thc
provision of care in the cardiac arrest setting clearly
exists. The pharmacy department in concert with the
hospital Pharmacy and Therapeutics Committee has a
defined and traditional role in maintenance of the
crnergcncy drug boxes (crash carts) located in various
parts of the hospital. Assuring that emergency drug boxcs
are appropriately stocked and meet the nccds of the
institution, a s mandatcd by the Pharmacy and Therapcutics Committee or other medicaf ovcrsight committee has
been a well-established support role for pharmacy
services for many ycars. As Advanced Cardiac Lifc
Support (ACLS) guidclines periodically changc and new
information related to pharmacothcrapcutic efficacy of
new and older drugs used in the cardiac arrest setting
becomes availablc, thc role of the pharmacist in updating
thc contcnts of the emergency drug box is critical to
maintaining the standard of care for drug delivery in the
cardiac arrest setting.
In addition to thcir role in drug delivery, thc pharmacists role of educator in the appropriatc use of drug
therapy in the cardiac arrest patient has been established
in a number of hospitals across the United States. This
educational role is important for several rcasons. First.
because cardiac arrests occur infrcyucntly, cspccjally in
noncritical care areas of the hospital, thc medical and
nursing staff may not be as familiar with either the
pharmacotherapeutic guidelines established by ACLS
rccomniendations or the appropriate administration tcchniques for AC1.S drug a s are providers in critical care
areas. Second, even in critical care units, implementing
change in longstanding ACLS drug administration bchaviors (modifying the role of lidocaine or sodium bicarbonate use) is often resisted by clinicians, but it is
often csscntial to the provision of quality care. Third,
dcspitc the fact that changes in the official ACLS drug
therapy guidelines occur only cvcry 5-6 ycars, the results
of landinark clinical trials often dictate changes in therapy
prior to thcir incorporation into published guidclincs.
in many hospitals have takcn active roles in
teaching physicians, nurses, and affiliated health professionals the pharmacology and therapeutics of drugs used
in the ACLS guidelines.

Cardiac A ~ ~ e s ~ ~ m Pharmacy
e r ~ ~ nServices
c ~

The education and training nceds of pharmacists who

scrve as members of the cardiac arrest team vary from
those that may be provided in some schools of phannacy.
All health care providcrs, as well as most laypcrsons,
should be certified in Basic Life Support (BIS). In a study
using questionnaires to determine attitudes toward and
use of cardiopulmonary resuscitation training received in
a school or pharmacy, 72% of responding graduates survcycd bclieved that a CPK-KLS program should be mandatory for graduation. Seventy percent of respondents
believed that thcir training would be o f value in their
current practice, and 93% believed that such training
would be of value in the future, dcspitc thc fact that only
5% had actually performed CPK since graduati~n.~
Clearly, pharmacist members of a cardiac arrest tcam
should possess BLS skills. In addition, since automatcd
extcrnal defibrillators have been dernonstratcd to improve
the chances of out-of-hospital cardiac arrest, training in
the use of thcsc devices is becoming an inherent part of
BLS training both within hospitals and in routine BLS
out-of-hospital training.x,In addition to the prerequisite
BLS training, cardiac arrest team pharmacist should be
certified in ACI.S, [he procedure in which most drug
therapy is instituted in the cardiac arrest setting. Even if
the role of the pharmacist a s a team member is limited to
drug preparation or documcntation, it is csscntial that the
pharmacist understand the rationale, efficacy, and potential sidc cffccts associated with the use of the drug therapy
bcing implemented. As in all other clinical pharmacy
practices, thc cardiac arrest team pharmacist should be
trained to monitor for both the efficacy and side effects of
the agents being used.
The need for the cardiac arrest team pharmacist to be
certified in ACLS is further rcinforced by the standards
developed by the Joint Commission on Accredivation of
Health Care Organizations (JCAHO) related to in hospital
cardiac arrests. O Of the several standards adopted by the
commission, several relate to activities in which the
pharmacist may have a significant role. These standards
includc the development of appropriate policies, procedures, proccsses or protocols governing the provision of
resuscitative services, appropriate data collection related
to thc process and outcomes of resuscitation, and ongoing review of outcomes, in the aggregate, to identify
opportunities for improvement of resuscitative efforts.
According to the Bethesda Conlerence on Cardiopulmonary Rcsuscitation, the majority of U.S. hospitals are dcficicnt in one or more of the areas in which thcsc new
JCAWO standards have been cstablished and will requirc
significant restructuring of thcir resuscitative efforts. I It

Cardiac ArresUEmergency Pharmacy Services

is clear that a real opportunity exists for the pharmacist to

influence those efforts related both to the improvement of
drug use policies, and to the creation of quality improvement and feedback processes that can identify and
improve hospital resuscitative efforts. Despite the assumption that hospitals function as self-contained emergency medical services (EMS) systems with respect to
their management of cardiac arrest based on their
abundance of health care providers in a defined environment, the Bethesda Conference report stated, "the process
of improving resuscitation in the hospital remains in its
infancy." Such an assessment presents a unique opportunity for pharmacy to establish itself as a necessary
component of a process that has become a part of required
standards of hospital care.

MERGENCY MEDICAL SERVl

Pharmacists have provided clinical services in emergency
medicine-related areas of hospitals since the late
1960s."*] Documentation of clinical pharmacy services
relate primarily to the provision of services in hospital
emergency departments. Services vary from those provided fundamentally as support to the emergency department staff, to those provided directly to patients in
specific disease management program^."^ 14' In a report
of follow-up observations on 3787 pharmacotherapy consultations provided in an emergency department in a university hospital, 33% involved patients with pulmonary
disease, 22% involved toxicology cases, 17% involved
patients with seizure disorders. 11% involved cardiac
cases, 7% were pharmacokinetic consultations, and 8%
were miscellaneous consultations."'] Consultations averaged 100 minutes each, and serum drug concentration
determinations primarily involved theophylline, phenytoin, phenobarbital, and acetaminophen. An early questionnaire of the value of clinical pharmacy services in a
medical center emergency department setting reported
that clinical pharmacy services added benefit to both
patient care and to educational programs in the department.[16] Eighty-seven percent of the responding physicians reported the pharmacist capable of providing
primary care to specific patients once a physician-based
diagnosis was established. Ninety-five percent of responders believed that clinical pharmacy services could be
transferred to other emergency departments, and 83%
were willing to have their patients charged for clinical
services provided by the pharmacist. A more recent evaluation of the utility of clinical pharmacy services in the
emergency department revealed that provision of a 24hour consultative service by clinical pharmacy residents

117

provided 3.1 consultations per 14-hour call period. Ninety

percent of these consultations were completely followed
by the recipient physician^."^] Clinical pharmacy services
involving a pediatric subspecialty emergency practice has
been described in which a pharmacist is a member of a
pediatric trauma team consisting of a pediatric surgeon,
neurosurgeon, emergency physician, intensivist, radiology
technician, and an intensive care unit nurse.1181
Opportunities for clinical pharmacy service in the
emergency department may expand because of the considerable effects resulting from changes in health insurance provision in the United States focused on reducing the number of hospital admissions. Perhaps the
most prominent example of clinical pharmacy services in
the emergency department setting is related to the management of asthma. The number of asthma-related deaths
in the United States is increasing, especially among
children. One potential cause for this increase may be
inappropriate early discharge of patients from emergency
departments. Pharmacists have participated in interdisciplinary efforts to maximize the urgent care of asthma patients in a number of environments, including the
emergency department. In a university-affiliated urban
teaching hospital, the number of emergency department
visits for a group of asthma patients was significantly
reduced after institution of a comprehensive program of
asthma management."']
Finally, a number of nontraditional practice sites have
been described in which pharmacist have participated in
natural disaster relief or as part of a humanitarian effort
relief team. These nontraditional practices have included
a pharmacy consultative service for wilderness emergency drug planning, pharmacy involvement in emergency preparednesslresponse, the provision of pharmaceutical services at a medical site after Hurricane
Andrew in Florida, and the experience of several pharmacists providing service in B o s n i a - H e r z e g ~ v i n a . ~ ~ ~ - ~ ~ ~
In conclusion, there are numerous current emergency
practice opportunities in which pharmacists play a
significant role. Although the number of pharmacists
who provide clinical services in these settings is relatively
small, the critical nature of drug use in such setting
suggests that the potential for direct pharmacotherapeutic
intervention is large. Well-designed outcome evaluation
of such service is sorely needed.

1. Edwards, G.A.: Samuels, T.M. The role of the hospital

pharmacist in emergency situations. Am. J. Hosp. Pharm.
1968, 25, 128-133.

Cardiac Arrestmmergency Pharmacy Services

I18

2.

X.

9.

10.

I I.

12.

Shimp, L.A.; Mason, N.A.; Tocdter, N.M.: Atwater, C.B.;

Corenflow, D.W. Pharmacist participation in cardiopulmonary resuscitation. Am. J. Health-Syst. Pharm. 1995, 52
(9). 980-984.
Bond. C.A.; Raehl, C.L.; Pitterle, M.E. 1992 National
clinical pharmacy services survey. Pharmacotherapy 199
14 ( 3 ) , 282-304.
Bond, C.A.: Raehl, C.L.; Pittcrlc, M.E. 1992 National
clinical pharmacy services survey. Pharmacotherapy 1998,
18 (2), 302 326.
Bond, C.A.; Raehl, C.L.; Pitterle, M.E. 1992 National
clinical pharmacy services survey. Pharmacotherapy 2000,
20 (4), 436-460.
Elcnbaas, R. Pharmacist on resuscitation team. N. Engl. J.
Med. 1972, 287 ( 3 ) , 151.
Bond, C.A.; Rcahl, C.L. Pharmacists attitudes toward the
use of cardiopulmonary resuscitation training received in
pharmacy school. Am. J. Hosp. Pharm. 1989, 46 (7),
1392- 1394.
White, R.D.; Asplin, B.R.; Bugliosi, T.F.; Hankins, D.G.
High discharge survival rate after out-of-hospital ventricular fibrillation with rapid defibrillation by police and
paramedics. Ann. Emerg. Med. 1996, 28, 480-485.
White, R.D.; Hankins, D.G.; Bugliosi, T.F. Seven years
experience with early defibrillation by police and paramedics in an emergency medical services system. Resuscitation 1998, 39, 145 -151.
Comprehensive Accreditation Manual ,for Hospitals: The
Official Handbook ( C A M H J ,Joint Commission Resources,
Inc.
Ewy, G.A.; Ornato, J.P. 3 I st Bethesda conference.
Emergency cardiac care. Task force 1: Cardiac arrest. J.
Am. Coll. Cardiol. 2000, 35 (4). 832 846.
Edwards, G.A.; Samuels. T.M. The role o l the hospital
pharmacist in emergency situations. Am. J. Hosp. Pharm.
1968. 25 ( 3 ) , 128 133.
Culbertson, V.; Anderson, R.J. Pharmacist involvement in
emergency room services. Contemp. Pharm. Pract. 1981, 4
( 3 ) ; 167- 176.
~

13.

14. Powell, M.F.; Solomon, D.K.; McEachen, R.A. Twentyfour hour emergency pharamaceutical services. Am. J.
Hosp. Pharm. 1985, 42 (4), 831-835.
15. Berry: N.S.; Folstad, J.E.; Bauman, J.L.; Leikin, J.B.
Follow-up observations on 24-hour pharmacotherapy
services in the emergency department. Ann. Pharmacother.
1992, 26 (4), 476 480.
16. Elenbaas, R.M.; Waeckerle, J.F.; McNabney, W.K. The
clinical pharmacist in emergency medicine. Am. J. Hosp.
Pharm. 1977, 34 (X), 843 846.
17. Kasuya, A.; Bauman, J.L.; Curtis, R.A.; Duarte, B.;
Hutchinson, R.A. Clinical pharmacy on-call program in
the emergency department. Am. J. Emerg. Med. 1986, 4
( 5 ) ; 464-461.
18. Vernon, D.D.; Furnival, R.A.; Hansen, K.W.; Dillcr, E.M.;
Bolte, R.G.; Johnson, D.G.; Dcan, J.M. Effect of a
pediatric trauma response tcam on emergency departmcnt
treatment time and mortality of pediatric trauma victims.
Pediatrics 1999, 103 (l), 20 24.
19. Pauuley, T.R.: Magee, M.J.; Cury, J.D. Pharmacistmanaged, physician-directed asthma management program
reduces emergency department visits. Ann. Pharmacother.
1995. 29 (l), 5-9.
20. Closson, R.G. The pharmacist as consultant for wilderness
emergency drug planning. J. Am. Pharm. Assoc. 1977, 17
(12), 746-749.
21. Moore, S.R. Pharmacy involvement in emergency preparednessiresponse. J. R. Soc. Health 1998. 118 (l), 2830.
22. Nestor, A,; Aviles, A.I.; Kummerle, D.R.; Barclay, L.P.;
Rcy, J.A. Pharmaceutical services at a medical site after
hurricane andrew. Am. J. Hosp. Pharm. 1993, 50 (9),
1896-1898.
23. Bussieres, J.F.; St-Arnaud. C.: Schunck, C.; Lamarre, D.;
Jouberton, F. The role of the pharmacist in humanitarian
aid in Bosnia-Herzegovina: The experience of pharmaciens sans frontiers. Ann. Pharmacothcr. 2
112-118.
~

PROFESSIONAL DEVELOPMENT

University of Illinois, Chicago, Illinois, U.S.A.

The roots of the clinical pharmacy movement are firmly

imbedded in cardiology as a discipline. From the bcginning, clinical pharmacists emphasized and specialized in
cardiology pharmacothcrapy. This is not surprising given
several factors: the overall prevalencc of hcart disease in
the United States, the prominence of cardiology as a discipline within medicine, and thc fact that the cornerstone
of the treatment of heart disease is drug therapy. Indeed,
cardiac drugs tend to be complex, rcplete with drug interactions and narrow therapeutic margins and the need
for close therapeutic monitoring, so that contributions by
pharmacists to the care of patients with heart disease seem
to be natural. The exact history of cardiology clinical
pharmacy remains ill-defined, but programs with intensive training in cardiology therapeutics in thc mid- 1970s
were the University of Missouri at Kansas City and the
University of Texas at San Antonio. Of note, E. Grey
Dimond, MD, a founding member of the American College of Cardiology, also initiated the clinical pharmacy
program at Truman Mcdical Center and the University of
Missouri at Kansas City School of Medicine. Strong
training programs (specialized residencies and/or fellowships) subsequently developed in the early 1980s at the
Univcrsity of Tllinois at Chicago, the University of Tcnnessee, and the [Jnivcrsity of Connecticut. Graduates of
these programs in turn seeded many academic health
centers and colleges of pharmacy throughout the United
States. Today, many cardiology clinical pharmacists can
trace their ancestry to a few of these programs.
Cardiology within pharmacy is not a stand-alone specialty. Rather, it is viewed as a subspecialty of sorts within
the umbrella spccialty of clinical pharmacy (or pharmacotherapy). In 2000, the Board of Pharmaceutical Spccialties designated a proccss whereby a board-certified
pharmacotherapy specialist may apply for added qualifications in cardiology pharmacothcrapy practice. The
applicant must submit a portfolio that documents training,
clinical practicc, educational efforts, and scholarly activities (among other details) spccifically within cardiology.
I<nnc.yclopc.diciof Clinical 1~lirrr.rnac.y
DOI: 10.1081E-ECP 120006398
Copyright 0 2003 by Marcel Dckkcr, Inc. All rights reaervcd

For this process to bc approved by the Board of Pharmaceutical Specialties, a petition was submitted (and
subsequently approved) outlining the rationale, necd, and
demographics of the subspecialty, along with appropriate
supporting information. This petition was prepared by the
Cardiology Practice and Research Network (P
American College of Clinical Pharmacy (ACCP); within it
are a number of facts that help to definc the discipline:
1. In 2000, there were about 30 fellowships or specialized residencies in cardiology clinical pharmacy in the United States.
2. About 13% of all board-certified pharmacotherapy
specialists list cardiology as the main emphasis of
their practice.
3. The Cardiology PRN of ACCP has about 400
members, one of the largest subspecialties within
this organization.
4. About 1100 members list cardiology practice as
thcir primary emphasis on membership surveys of
ACCP (750) and the American Society of HealthSystem Pharmacists (350).
5. From a survey of board-certified pharmacothcrapy
specialists performed for the BPS petition for
added qualifications in cardiology, the following
was listcd as the respondents practice area: cardiac intensive care (40%), stcpdown/tclemetry unit
(26%), anticoagulation clinic ( 1 S%,), lipid clinic
(18%), managed care (7%),and other primary care
clinic (35%). Of those responding, 24% had fellowship training, 13% had a specialized residency,
and 19% had complcted a certificate program.

Although the discipline of clinical pharmacy (or pharmacotherapy) within organized medicine is relatively
young, specialized practice in cardiology is one of its more
maturc areas. It is not a stand-alone specialty because one
uses the principles and skills of the specialty pharmacotherapy (as it is presently defined) simply applied to an
area of itnowledge (i.c., cardiology therapeutics). There
are numerous citations documenting the role of and oul119

120

comes (clinical and economic) associated with clinical

pharmacy practice in cardiology settings. These are summarized in the following sections. One will find that the
role of pharmacists providing services to targeted areas
(e.g., lipid clinic, anticoagulation clinic, smoking cessation) in ambulatory settings is much more frequently
studied than the role of the pharmacist practicing in an
acute care, inpatient setting where the clinical functions
are more broad.

ACUTE CARE CARDIOL

Twenty-five percent of Americans discharged from hospitals have a primary diagnosis of cardiovascular (CV)
disease.] The pharmacist practicing in an acute care
setting helps manage common cardiac disease states, including the spectrum of acute coronary syndromes (ACS),
hypertensive emergencies and urgencies, acute heart failure, and cardiac arrhythmias, along with comorbid conditions. Decisions regarding optimal medication use in
such patients are complex. Beginning with the initial
choice of medication to treat a patient acutely, and through
selection of appropriate chronic therapy and proper titration and monitoring, the acute care pharmacist is a vital
component in the system of health care provision.
As part of the health care team, the acute care pharmacist works with attending physicians, physicians-intraining nurses, and other health care professionals to provide patient care. Daily activities are often centered around
medical rounds, where the team reviews each inpatients
progress over the last day. Here, drug therapy decisions are
made within the constructs of a team approach. Information shared during rounds includes results of lab tests,
physical exams, diagnostic and therapeutic procedures,
and symptomatology. Using this information, a pharmacist
assists in evaluating patient response to medications, including assessing dose, route, and monitoring of each drug
that the patient is receiving. When prospectively adding a
medication to the patients orders, the pharmacist recommends appropriate agents based on the clinical indication,
dosing (initial and target), and both efficacy and safety
monitoring parameters. In providing such information, the
pharmacist becomes a primary source of education regarding optimal medication use for all the members of the
health care team. Other tasks the pharmacists might perform include obtaining medication histories from patients
admitted to the hospital, patient medication education, and
discharge counseling for patients discharged from the
hospital on a new medication regimen.
An important role for the pharmacist is prevention of
adverse drug events (ADEs), which significantly contrib-

Cardiology, Clinical Pharmacy Practice in

ute to health care costs in numerous ways, including increases in lengths of stay, medication, and laboratory
costs. Medications used in acute cardiac settings tend to
have narrow therapeutic windows with substantial risk for
toxicity and require close monitoring to optimize therapy
(e.g., antithrombotics, antiarrythmic agents, intravenous
inotropes, nitroprusside). Drug-drug interactions (also
quite common with cardiac regimens), inappropriate dosing, and inappropriate drug selection are just a few examples of common ADEs where pharmacy intervention
could have a tremendous impact. An important study by
Leape et al. noted that the inclusion of a clinical pharmacist on a multidisciplinary team rounding in an intensive care setting reduced ADEs by 66%, through order
clarification, provision of drug information, and recommendations of alternative therapy.[31
A unique responsibility of a cardiology specialty pharmacist is the management of drug therapy of ACS,
particularly those involving unstable angina and cardiac
catheterization-associated procedures. Low-molecularweight heparins and glycoprotein IIb/IIIa receptor antagonists are newer treatment modalities, but are considerably more expensive than older medications used for
ACS. Newer thrombolytics used in treatment of acute
myocardial infarction are easier to administer (in one or
two bolus doses versus an infusion), yet are more expensive. Therefore, there is a need to develop cost-effective
treatment strategies that encompass these newer agents.
These strategies must take into account critical literature
evaluation (i.e., are there superior outcomes between
studies involving the newer agents?) and knowledge of
patient characteristics (i.e., determining if the patient has
an appropriate indication for use of a new therapy, identifying appropriate dosage adjustments in the face of renal
insufficiency) when formulating guidelines. The cardiology specialty pharmacist may play a significant role in
developing such guidelines for the institution, selecting
individual patients for therapy, and selecting which
therapy to use in particular ACS scenarios.
It is common to find a pharmacist as a member of the
hospital cardiopulmonary resuscitation (CPR) team, which
responds to emergent situations that may require immediate patient care. These scenarios usually involve a patient who suddenly becomes nonresponsive, ceases spontaneous respirations, and/or experiences a life-threatening
cardiac arrhythmia. The CPR team responds to such patients by implementing advanced cardiac life support
(ACLS), which involves quick provision of an airway and
electrical (defibrillation) and/or pharmacologic interventions to sustain cardiac function. The pharmacists role on
such a team involves the preparation of intravenous infusions needed in an emergent situation, dose calculations,
and consultation regarding appropriate medication use.

Cardiology, Clinical Pharmacy Practice in

Participation by a pharmacist on a CPR team was associated with significantly lower hospital mortality rates in a
study by Bond and colleagues.[41

121

therapy. In addition, a pharmacist can provide patient

education regarding the importance of compliance, adverse effects, and goals of therapy, thereby increasing the
likelihood of successful control of patients' disease states.

Dyslipidemia
SPECIALTY PRACTICE
In the outpatient setting. cardiology pharmacists frequently provide services in a wide array of clinic types, including general cardiology clinics, primary care/family
medicine clinics, and disease management clinics. The
impact of a cardiology pharmacist in these settings has
been clearly documented in the medical literature. Generally, a pharmacist's knowledge of CV disease state
pathophysiology , presentation, and course, coupled with
extensive knowledge of drug therapy options and monitoring are invaluable insofar as enhancing comprehensive
patient care. The following is a description of types of
specialty care that a pharmacist might provide.

Hypertension
Some of the earliest published reports on the effects of
provision of pharmaceutical care provided insight into the
effects of a pharmacy program in the care of patients with
hypertension. In an early study by McKenney and colleagues, the effects of clinical pharmacy services in a
group of hypertensive patients were d e ~ c r i b e d . ~Those
~]
patients who received pharmacy services in addition to
standard care by their physician demonstrated an improvement in self-knowledge of their disease state, improved compliance. and better blood pressure control.
Subsequent investigations have demonstrated a positive
effect of pharmacy services on cost and quality of life in
patients treated for h y p e r t e n ~ i o n . ' ~ ~ ~ ]
In this largely asymptomatic yet morbid disease, early
identification and treatment are the mainstays for excellent patient care. The proper management of a hypertensive patient begins with selecting an appropriate goal
blood pressure, recognizing other risk factors for CV disease, noting concomitant disease states, and selecting
appropriate drug therapy for the patient. When selecting
such therapy it is important to bear in mind compelling
indications (as defined in the Sixth Report for the Joint
National Committee on the Detection, Evaluation, and
Treatment of High Blood Pressure,"] which is the consensus guidelines for the treatment of hypertension), contraindications or cautions for using certain classes of
medications, patient compliance, and cost. As a drug expert, pharmacists are in an ideal position to enhance care
through the selection and monitoring of antihypertensive

Dyslipidemia is a major risk factor for several CV diseases, including myocardial infarction, stable and unstable angina, and stroke. Control of cholesterol levels is
important in reducing risk of both primary and secondary
CV events. High cholesterol levels may be treated by
altering diet and through pharmacologic intervention.
Outpatient dyslipidemia clinic models that include intervention by a clinical pharmacist have demonstrated
larger reductions in total cholesterol level, greater likelihood for achieving National Cholesterol Education Program"] low-density lipoprotein goals, and better medication compliance."0-'21
The decision to start cholesterol-lowering therapy can
be complex and should involve patient assessment for
concurrent risk factors (hypertension, diabetes), concomitant medications, diet, and social history (alcohol and
cigarette use). The pharmacist can recommend and counsel regarding nonpharmacologic interventions such as reduction in body weight, dietary alterations, exercise, and
cessation of cigarette smoking. It is also important to ensure that comorbid disease states (diabetes, hypertension)
are adequately treated and monitored. If the decision is
made to start a cholesterol-lowering agent, the pharmacist
must ensure that the appropriate agent is selected because
each agent may have a distinct effect on each lipoprotein
component (low density, high density, triglycerides) of
the lipid profile. In addition, prospective identification
and avoidance of drug interactions when using cholesterol-lowering therapy is a salient pharmacist responsibility. For example, IlMG CoA reductase inhibitors (some of
the most commonly used cholesterol-reducing medications) are agents that inhibit a major metabolizing enzyme
in the liver and may be a source of clinically significant
drug interactions, including the occurrence of myositis,
rhabdomyolysis, or renal dysfunction. Recommendation
of pertinent monitoring parameters and patient education
are additional contributions that the clinical pharmacist
can make when caring for the dyslipidemic patient.

Chronic Heart Failure

There are many drug therapy-specific tasks unique to the
care of a heart failure patient. A thorough review of the
medication profile of a patient with heart failure should
include ensuring the presence of appropriate medications

I22

(ACE inhibitors, beta blockers) for reducing mortality

related to this devastating disease. Cardiology pharinacists can optimizc therapy by identifying and achieving
goal doses (those doses achieved in clinical trials of heart
failure) for each of these mcdications, depending on
patient tolerability. Of equal importance is a check for
mcdications that may potentially exacerbate heart Failure
or cause toxicity when given in conjunction with existing
heart failure therapy.
Numerous trials document that many patients do not
always rcccivc drugs shown to decrease mortality in heart
Failure (c.g., ACE inhibitors) or do not rcccivc the proper
("goal") doses (see studics by Smith et al."" and Roe
et a1."41). Clearly, cardiology pharmacists have an impact
on outcomes related to the use of these medications by
ensuring appropriate dosing parameters. Such responsibilities may include recognition of an appropriate patient
for ACE inhibitor or beta blocker therapy, proper uptitration of each agent, management of advcrsc effects related to therapy, and identification of true ACE or beta
blocker intolerance.
Gatlis and colleagues demonstrated the valuable contributions made by a clinical pharmacist in the care of
patients with heart failure.' ''I In this study, pharmacists
made therapy recommendations (including ensuring attainment of goal doses of heart failure medications,
avoidance of contraindicated medications), provided patient education regarding medical therapy, and monitored
for adverse drug events. By providing intensive pharmacy
services, the investigators were able to demonstrate a
reduction in all cause mortality, attainment of higher ACE
inhibitor dose, and greater use of alternate vasodilators in
those patients intolerant to ACE inhibitors.

Antithrombotic therapy is used in myriad CV diseases

such as atrial fibrillation, heart failure, valve replacement,
peripheral vascular disease, and stroke. This presents an
ideal setting for a pharmacist-managed antithrombosis
clinic. Today, inany institutions have antithrombosis clinics managed by clinical pharmacists; this trend continues
to grow.
In such a clinic, a pharmacist is responsible for the
careful, periodic monitoring of prothrombin time (or international norrnalizcd ratio [INRI) to ensurc safe and
efllcacious therapy with oral anticoagulants such as warfarin. In addition, the pharmacist emphasizes patient eduation regarding adverse effects, vitamin K-containing
diets, and potentially interacting drugs. The patient's drug
profile should be reviewed at every visit (for prescription
and over-the-counter medication) to prevent possible drug

Cardiology, Clinical Pharmacy Practice in

interactions. Guidance is also provided to other health care

providers regarding appropriate dosage changes and
monitoring parameters.
Numerous siudies have described clinic models and
outcomes related to pharmacist-managed antithrombosis
clinics. Chiquettc and colleagues demonstrated fewer incidences of supratherapeutic levels of anticoagulation,
more consistent maintenance of appropriate levels of anticoagulation, lower rates of bleeding complications, and
thromboembolic events in a group o f patients managed in
a pharmacist-managed clinic versus those managed by
usual medical care.'
These investigators also showed
lower rates of hospital admissions and emergency dcpartinent visits due to warfarin therapy in those patients managed in the clinic. Similar superior care was noted in investigations published by Wilt and colleagues who also
demonstrated a 20-fold increase in events (warfarin-rclated hospitalization, hemorrhagic or thrombotic events) in
patients cared for in a family practice setting versus a
pharmacist-managed clinic.' 17' Both of these invcstigalions translated these reduced event rates into significant
cost savings; Chiquette estimated annual health care
costs would be reduced by more than $130,000 per 100
patients, whereas Wilt attributed a $4000 cost avoidance
per person-year of follow-up for those patients managed
by a pharmacist.
Other antithrombotic therapies that arc managed by
pharmacists include the oral antiplatclct agents ticlopidine
and clopidigrel, which are used for therapy for ischemic
stroke and postcoronary stent placement. As with warfarin, therapy with these medications requires specific
monitoring (especially of blood counts) and patient education. Another potential role for an antithrombosis pharmacist is management of patients on low-molecularweight heparin (c.g., enoxaparin). As the use of these
agents has expanded to the outpatient setting, particularly
as a transition to oral anticoagulant therapy, the need
exists for a skilled clinical pharmacist to maintain cffcctive and safe treatment with the agents. Dedden and colleaugcs published a report on a pharmacist-managed program to treat proximal deep vein thrombosis."" Patients
were treated at home with enoxaparin and warfarin until
the patient's TNR was therapeutic; all therapeutic monitoring was done by pharmacists. In treating 55 patients, a
total of 294 patient hospital days were avoided, which
could be translated into significant cost savings.

'"

es
Given the many clinical conditions related to or caused by
cardiac conditions combined with the numerous medications used to treat such conditions, it is clear that the po-

123

Cardiology, Clinical Pharmacy Practice in

tential for pharmacist collaboration in the care of cardiology patients is endless. Other clinic types described in
the literature include pharmacist-managed smoking cessation clinics' - 221 amiodarone monitoring clinics,[231
and cardiac medication assistance programsi241(for those
who cannot afford these medications).

NET

TUNlTl

Many cardiology clinical pharmacists collaborate closely

with their physician colleagues in patient care and scho-

Clinical Trials
*Kinetics/Dynamics
.Drug information
4htcomeslEconomi

larly matters. Presentations of the results of major clinical

trials that will influence the daily practice of clinicians
compel many to attend major medical cardiology meetings, such as the annual meetings of the American Heart
Association or the American College of Cardiology, and
follow cardiology specialty journals such as Circulation,
Journal of the American College of Cardiology, American
Journal of Cardiology, and American Heart Journal,
among others. However, the primary forum for networking of cardiology clinical pharmacists is through the
Cardiology PRN of the ACCP. This group meets at the
annual meeting of ACCP, and maintains a useful and ac-

i-\
HMOIMCO

*CHF
*HTN
*Lipids
.Smoking Cessation
*Anti-thrombosis
~Amiodarone

*MI/ACS
.CHF
*HTN
*Arrhythmias
-ACLS

Fig. 1 Representation of the spectrum of cardiology clinical pharmacy practice. Clinical pharmacists may use their skills and knowledge
of the drug treatment of heart disease in a variety of sites (large circles) such as the pharmaceutical industry, health care systems,
ambulatory care, or inpatient settings. Specific duties are listed inside the large circles: they may include the direct care of patients
(inpatient and ambulatory practice) or more global responsibilities for drug use (health care systems and industry), and overlap to some
degree. The smaller circles represent more specific practice sites for each of the respective areas. Abbreviations: HMO, health
maintenance organization; MCO, managed care organization: GPO, group purchasing organization; AHC, academic health center;
Comm, community; Pharm, pharmacy or pharmaceutical; CICU, cardiac intensive care unit; CHF, congestive heart failure; HTN,
hypertension; MI/ACS, myocardial infarctiodacute coronary syndromes; ACLS, advanced cardiac life support (i.e., cardiac arrest team).

124

tive listserv for discussion on therapeutic problems or issues in clinical pharmacy practice.

There are numerous opportunities for cardiology clinical

pharmacists, and these opportunities appear to be expanding (Fig. 1). Traditionally, positions with a predominantly
clinical practice focus were concentrated in academic
medical centers, often those affiliated with a college of
pharmacy. Here, clinicians would practice-either collaboratively (particularly in an inpatient setting) within a
health care team on cardiology units or independently
(particularly in an ambulatory setting)-to manage specialized clinics. Typically, this type of clinician has
teaching duties and some scholarly duties, in addition to
clinical responsibilities. These roles have expanded to
some degree into community hospitals as the clinical
pharmacy movement grew. Further, because of the shift to
managed health care, some clinical pharmacists with skills
in cardiology may take responsibility for the drug use in a
health care system, managing formularies and developing
systemwide treatment guidelines and drug-use policies.
Here, cardiology clinical pharmacists use their skills and
knowledge to effect drug use in populations of patients
with heart disease rather than select individuals.
For positions with a research focus, cardiology clinical
pharmacists (usually with research fellowship training)
have opportunities as clinical science faculty at researchintensive universities (colleges of pharmacy and/or medicine) or in the pharmaceutical industry. In industry positions, cardiology clinical pharmacists may coordinate
clinical trials (phase III and IV) or work in drug disposition and pharmacokinetics. These types of positions
remain, but other opportunities have arisen more recently.
For instance, opportunities in the pharmaceutical industry for medical service managers or medical liaisons
have expanded. These individuals may coordinate some
smaller. single-site research projects (e.g., phase IV),
have educational responsibilities to physicians and pharmacists. and also have a minor sales component within
their duties (or combinations of all of the above, depending
on the specific company). The industry is seeking sophisticated health care professionals who can represent the
company and their products on a sophisticated level; thus,
the cardiology clinical pharmacist seems well suited for
such positions.
Last, there has been an expansion of cardiology clinical pharmacy into ambulatory settings. Due in part to
prospective and fixed payment systems and the growing
sophistication of pharmacists in therapeutic decision mak-

Cardiology, Clinical Pharmacy Practice in

ing, cardiology clinical pharmacists can find opportunities

in managing disease state-specific clinics such as the ones
previously reviewed (e.g., antithrombosis, smoking cessation, heart failure lipid management). Indeed, it has
become very common (if not standard of care) for health
care systems to employ cardiology pharmacists to manage
outpatient antithrombosis treatment (e.g., warfarin, lowmolecular-weight heparin). Usually, this is accomplished
by establishing approved treatment protocols and collaborative drug therapy agreements with physician colleagues. It should be noted that a growing number of states
have passed legislation to allow collaborative drug management by pharmacists (i.e., prescriptive authority under
approved protocols and/or agreements with physicians).
The next frontier is cardiology clinical practice in
community pharmacy settings. It is hoped that the progress
made in ambulatory practice can be extrapolated into these
environments. This possibility has been fueled by demonstration projects where pharmacists receive financial payments for cognitive services. Noteworthy is that some of
these initial disease state management efforts (e.g., management of hypertension, lipid disorders, and thrombosis)
require practice skills and specialized knowledge in cardiovascular pharmacotherapy .

General
American Heart Association web site: www.americanheart .org .

Acute coronary syndromes

Ryan TJ; Antman EM; Brooks NH; Califf RM; Hillis
LD: Hiratzka LF; Rapaport E; Riegel B; Russell RO;
Smith EE 111; Weaver WD. 1999 update: ACC/AHA
guidelines for the management of patients with acute
myocardial infarction: executive summary and recommendations: a report of the American College of Cardiology/American Heart Association Task Force on
Practice Guidelines (Committee on Management of
Acute Myocardial Infarction). Circulation. 1999, 100,
1016- 1030.
Braunwald E; Antman EM; Beasley JW; Califf RM;
Cheitlin MD; Hochman JS; Jones RH; Kereiakes D;
Kupersmith J; Levin TN; Pepin CJ; Schaeffer JW;

Cardiology, Clinical Pharmacy Practice in

125

Heart failure
Smith EE 111; Steward DE; Theroux P. ACC/A
2002 Guideline update for the management of patients
* Hunt SA, Baker DW, Chin MH, et al. ACC/AHA
with unstable angina and non-T-segment elevation
guidelines for the evaluation and mangement of
myocardial infarction: a report of the American
chronic heart failure in the adult: a report of the
College of Cardiology/American Heart Association
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sociation Task Force on Practice Guidelines (ComManagement of Patients with Unstable Angina). 2002.
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Available at: http://www.acc,org/clinical/guidelines/
and Management of Heart Failure. 2001. American
unstable/unstable.pdf.
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www .acc.org/clinical/guidelines/failure/hf_index.htm.
Stable angina
*

Gibbons R9; Chatterjee K; Daley J: et al. ACC/AHA/

ACP-ASIM guidelines for the management of ptients
with chronic stable angina: executive summary and
recommendations: a report of the American College of
Cardiology/American Heart Association Task Force
on Practice Guidelines (Committee on Management of
Patients With Chronic Stable Angina). Circulation.

Hypertension
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The Sixth Report for the Joint National Committee on

the Detection, Evaluation, and Treatment of High Blood
Pressure. Arch Intern Med 1 97, 157, 2413-2446.
yslipidemia

Executive Summary of the 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
. 285, 2486-2497.

Anti t hrombotic therapy

* Sixth ACCP Consensus conference on antithrombotic

01, 119 (suppl), 1-370S.
Atrial fibrillation
0

Fuster V, Ryden LE, Asinger RW. Cannom DS, Crijns

HJ. Frye RL. Halperin JL, Kay GN, Klein WW, Levy
S, McNamara RL. Prystowsky EN, Wann LS, Wyse
DG. ACC/AHA/ESC guidelines for the management
of patients with atrial fibrillation: a report of the
American College of Cardiology/American Heart
Association Task Force on Practice Guidelines and
Policy Conferences (Committee to Develop Guidelines for the Management of Patients With Atrial
Fibrillation). J. Am Coll Cardiol 20

Advanced cardiac life support

*

The American Heart Association in Collaboration with

the International Liaison Committee on Resuscitation
(ILCOR). Guidelines 2000 for Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care.
Circulation 2000, 102 (suppl I), 1-1-1-384.

EF

1. The American College of Clinical Pharmacy Cardiology

Practice and Research Network. Executive Summary: Petition for Added Qualifications in Cardiology for Board
Certified Pharmacotherapy Specialists; 2000.
2. American Heart Association Web Page, www.americanheart.org, accessed November 2000.
3. Leape. L.L.;
Cullen, D.J.; Clapp, M.D.; Burdick, E.;
Demonaco, H.J.; Erickson, J.I.; Bates, D.W. Pharmacist
participation on physician rounds and adverse drug events
in the intensive care unit. JAMA 1999, 282. 267-270.
4. Bond, C.A.; Raehl, C.L.: Franke, T. Clinical pharmacy
services and hospital mortality rates. Pharmacotherapy
1999, 19: 556-564.
5. McKennep. J.M.; Slining, J.S.: Henderson, H.R.; Devins,
D.; Barr, M. The effect of a clinical pharmacy services on
patients with essential hypertension. Circulation 1973, 48,
1104-1 11 1.
6. Forstrom, M.J.; Ried, L.D.; Stergachis, A.S.: Corliss, D.A.
Effect of a clinical pharmacist program on the cost of
hypertension treatment in an HMO family practice clinic.
DICP 1990, 24>304-309.
7. Erickson, S.R.; Slaughter, R.; Halapy, H. Pharmacists
ability to influence outcomes of hypertensive therapy.
Pharmacotherapy 1997, 17, 140- 147.
8. The sixth report for the Joint National Committee on the
detection, evaluation, and treatment of high blood pressure.
Arch. Intern. Med. 1997. 157, 2413-2446.
9. National cholesterol education program. Second report of
the expert panel on detection, evaluation. and treatment of
high blood cholesterol in adults. Circulation 199
1333-1445.

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a c ~ in

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10. Bogden, P.L.; Koontz, L.M.; Williainson, P.; Abbott, R.D.

The physician and pharinacist teain: An effective approach
to cholesterol reduction. I . Gcn. Intern. Mcd. 1997, 12,
158 164.
1 1 . Shaffer, 1.; Wexlcr, I>.F.Reducing low-density lipoprotein
cholesterol in an ambulatory care system. Results of a
multidisciplinary collaborative practice lipid clinic c o n pared with traditional physician-based care. Arch. Intern.
Med. 1995. 155, 2330-233s.
12. Furrnaga, E M . Pharmacist management of a hyperlipideinia clinic. Am. J. Hosp. Pharm. 1993, 50. 91 95.
13. Smith, N.;Psaty. R.M.; Pitt, B.; Garg, I<.; Gottdiener,
J.S.; Hcckbert, S.R. Tcrnporal patterns in the medical
treatment of congestive heart failure with angiotcnsin
converting enzyme inhibitors in oldcr adults. I989
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18.

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Roc, C.M.; Motheral, B.R.; Tcitclbaum, F.; Rich. M.W.

Angiotensin converting enzyme inhibitor coinpliancc and
dosing among patients with heart failure. Am. Heart J.
1999, 138. 818 825.
1s. Gatlis, W.A.; Hasselblad, V.; Whellcn, D.J.; OConnor,
C.M. Reduction in heart failure events by the addition of a
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16. Chiquette, E.; Aniato. M.G.; Russey, H.I. Comparison of
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Dedden, P.; Chang: 3.; Nagel, 1).Pharmacy managed program for home trcatmcnt of deep venous thrombosis with
enoxaparin. Am. J. Health-Syst. Pharm. 1997, 54, 19681972.
Tommasello, T. Two pharmacy-practice models [or implementing the AHCPR smoking cessation guideline. Tob.
Control 1997, h (Suppl. l), S36- S 3 8 .
Crealey, G.E.; McElnay, .I.(:.;
Maguire, T.A.; ONeill. C.
Costs and effects associated with a corninunity pharmacybascd smoking cessation programme. Pharmacoeconornics
1998, 14. 323 333.
Sinclair, H.K.; Bond, C.M.; Lennox. A S . : Silcock, J.;
Winfield, A.J.; Donnan, P.T. Training pharmacists and
pharinacy assistants in the stage of change rnodcl of smoking cessation: A randomised controlled trial in Scotland.
Tob. Control 1998. 7, 253 261.
Sanoski, C.A.; Schocn, M.D.; Goiizalw, R.C.; Avitall, B.;
Rauman, J.L. Rationale, developmcnt. and clinical outcomes of a multidisciplinary amiodaronc clinic. Pharinacothcrapy 1998, 18. 146s -151s.
Carmichael, J.M.; OConncll, M.B.; Devine, B.: Kelly, W.;
Ereshefsky, I,.; 1,inn. W.; Stimmel, G.L. ACCP position
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Schocn, M.D.; DiDornenico, R.S.; Connor, S.E.; Ilischler,
J.E.: Bauman, J.L. Lrripact of the cob[ o f prescription drugs
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Pharinacotherapy 2001, 21, 1455 1463.

Pt 1ARMACY PRACTICE ISSUES

Cnto Resedrc h Ltd., Durham, North Carolin,i, U.S.A.

Allen Cato
C&o R ~ ~ r Ltd.,
c h San D i c y ~California,
,
U.S.A.

The process of developing a new drug, from the

identification of a potential drug candidate to postmarketing surveillance, is extremely complex. The drug
development process requires input from various members
of a multidisciplinary team and thc conduct of numerous
studies. Thc time from drug discovery to marketing takes
an average of 13 years. Once a chemical is identified as a
new drug candidate, extensive preclinical analyses must be
completed before the drug can be tcstcd in humans. The
pharmacology, toxicology, and prcclinical pharmacokinetics must be characterized. The formulations of the drug
product that were used in the prcclinical studies may be
different from the formulation of the final drug product,
which may require that additional formulation work and
pharmacokinetic analyses be performed. If the characteristics of the new drug candidate are acceptable for all of
thc preclinical assessments, it may then be tested in
humans. The new drug candidate, at this point, enters the
clinical research stage of drug development.
Clinical research represents a vital stagc in thc
development process a stage that is no less daunting than
the preclinical research stagc. The data obtained from the
first-time.-in-human,Phase I pharmacokinetic studies, and
initial safety evaluations in healthy volunteers can make or
break the entire developmental program for a drug
candidate. The sponsoring company, of course: hopes that
the data collected in thesc initial studies will show minimal
safety concerns over an adequate dose range. The
pharmacokinetic data can then be used to help design
future studies in which efficacy and long-term safety arc
assessed and additional pharmacokinetic and pharmacodynamic data are collectcd.
Although the basic designs of the initial single and
multiple dose-escalating studies are generally straightforward (but the starting dose is often intenscly debated), it is
imperative that these studies and future studies be deEizc.yr.lopdici o j Clinic.u/ 1harninc.y
001: 10.108l/E-ECP I2OO06410

Copyright :() 2003 by Marcel Dekker, Inc. All rights rcrcrvccl

signed to address specific questions. The questions vary

depending on numerous specific considerations, including
the targeted disease characteristics (e.g., acute or chronic);
desired safety, efficacy, and pharmacokinetic evaluations;
and assessment of clinical pharmacology (c.g., dosage
formulations or dose frequency). Basic study procedures
must also be considered. Thus, the design, conduct, data
reporting and analysis, and production of the final study
reports can be completed only through the coordinated
efforts of a multidisciplinary drug development team.
For every clinical study, input is required from multiple
personnel with various areas of expertisc. Members of a
drug development teain include physicians, scientists,
pharmacists, project managers, statisticians, computer
programers, study monitors, regulatory experts, and for
some studies, a rcprcsentative of the formulations group.
While some team members may be able to perform
multiple tasks, no one team member has the expertise or
the time to do everything requircd to conduct a clinical
study. In addition, some members may have overlapping
abilities, but other membcrs with particular expertise may
be called upon. For example, pharniacokincticists are
the experts in pharmacokinetics. but thcy may also bc
knowledgeable in pharmaceutics, biostati stics. and clinical
care. Howcvcr, scientists (PhDs) are trained primarily in
basic rescarch, while physicians (MDs) are trained in
clinical medicine. Since a single drug dcvclopmcnt
program is derived from both o f thesc distinct d
considerable ovcrlap, cooperation, and coordination are
necessary to take a drug successfully and efficicntly from
discovery to markct.
Clinical drug development is generally divided into
four phases: Phase 1 through Phase 4. For each study
conducted within a particular phase, specific information
is collectcd according to thc rcquiremcnts for individual
drugs being developed. Collection of safety, efficacy, and
pharmacokinetic data is the focus of most clinical trials.
Although these topics appear to be distinct disciplines,
B 27

12s

they are intertwined and represent different ways of

evaluating the intrinsic properties of a drug. While the
safety, efficacy. and pharmacokinetics of a drug may be
assessed in most studies. the team must establish the type
and extent of information to be collected, which will vary
based upon the specific objectives and designs of the
studies.
A critical function of the drug development team is
the development of the study protocol. The study
protocol must clearly describe the study design and
methodology that will be used to achieve the study
objectives. Input from nonmedical and nonscientific
members of the team, such as marketing and information
technology experts, also is helpful in establishing
development strategies and in designing and conducting
of clinical studies. Finally, project planning efforts can
synchronize team efforts, help contain the soaring costs
of pharmaceutical research: and coordinate international
development efforts.
The drug development teams primary goal is to gain
approval to market the drug, which requires that a
marketing application be submitted to a regulatory
agency (e.g., a New Drug Application [NDA] is
submitted to the Food and Drug Administration [FDA]
in the United States and to the Health Products and Food
Branch [HPFB] in Canada, while a Marketing Authorization Application [MAA] is submitted to European
regulatory agencies). During the conduct of the studies
and the compilation and analyses of the data, the team
must consider and evaluate many issues, such as how to
collect, categorize, and report adverse events. All of
these decisions will affect the marketing application that
is submitted and may ultimately define how the drug is
to be administered.
Many of the decisions to be made by the team, and
particularly by the investigators, pose ethical dilemmas.
Legislation has been enacted to protect human research
subjects. Recently, the most pressing ethical dilemma
facing the clinical research scientist concerned biotechnology and genetic engineering research.
Frequent changes in the regulations and guidelines of
various regulatory agencies, differences in interpretations
of these rules, and special reporting mechanisms for
adverse events represent only a few of the challenges
facing a drug development team. Due to continuous
advances in scientific information, understanding of
disease processes, and gene therapy, change continues to
be the rule in modern drug development. However,
through the efficient application of sound scientific
principles in an ethical manner and with a coordinated
team effort, effective new therapies can continue to be
developed and marketed.

Clinical Evaluation of Drugs

The physicians contribution to drug development and

the physicians role on a drug development team have
changed over the last few decades (1). Before the
1960s, medical departments of pharmaceutical companies were primarily composed of physicians who were
routinely involved in responding to drug information
requests rather than developing new drugs. The
Kefauver-Harris Amendment. enacted in 1962, required
pharmaceutical companies to demonstrate before marketing that a drug was efficacious. which necessitated
that physicians increase their presence on drug
development teams. Along with the advent of additional
governmental regulations, the increase in complexity of
medical knowledge has mandated that physicians
become an integral member of any drug development
team. In fact. because of the different roles of the
physician within an organization. companies may now
have various departments (e.g., a clinical research
department and a clinical safety department) within the
medical department.
Although physicians are trained in patient care,
physicians who are typically employed by pharmaceutical
companies have more training in scientific methodology
than those in the past. The physician on the team is the one
qualified to follow the progress of each patient enrolled in
a clinical trial and to interpret the results. Some physicians
continue to spend time treating patients at a university
hospital or a specific clinic where their specialty can be
utilized and practiced, which allows these physicians to
maintain sharp diagnostic skills. Also, some may perform
basic research in academic settings to develop or maintain
their knowledge and skills in basic research.
However, much of todays clinical research is actually
conducted by investigators who are not employed by
the company sponsoring the development of the drug.
The physician on the drug development team must help
in the selection of appropriate investigators to conduct the
clinical studies. Pharmaceutical physicians may rely on
colleagues who are experts in their respective fields and
who have appropriate patient populations and facilities for
the targeted research project. The physician is also the
expert who deals with emergency situations that may arise
during the course of a clinical research project, such as an
overdose or severe adverse experience (SAE) that might
be experienced with the drug. Similarly. the physician
assists investigators who are responsible for evaluating the
severity of adverse experiences (AEs) and determining

Clinical Evaluation of

the causal relationship of the AEs to the drug under

development.
The physicians involvement in clinical research does
not end with the completion of the clinical study. Medical
reports, clinical study reports, and sections of NDAs must
be written. Interactions with regulatory agencies that
require the physicians input may occur frequently.
Physicians in clinical research may also be called upon
to promote new drugs in a scientific environment by
organizing symposia and workshops and by reviewing
journal advertisements and promotional material for
medical validity and accuracy.
The role of the physician in a clinical drug development
program has expanded and has been refined in the last 40
years. Physicians increasingly contribute clinical and
scientific expertise and administrative skills. Many
physicians on drug development teams today spend most
of their time designing and implementing studies and
interpreting and reporting data rather than being in direct
contact with patients. An experienced clinician is an
important member of any drug development team.

Scientists
While a drug development team may have only one
primary physician, it may have multiple scientists.
Pharmacokineticists, pharmacologists, toxicologists, and
pharmaceutical scientists are all involved in the clinical
development of drugs. The contributions of scientists to a
drug development project are derived from their
experience in both scientific methodology and basic
research (1).
Although physicians are trained in patient care,
scientists are trained in problem-solving skills related to
scientific research. To obtain a doctoral degree, a
scientist must conduct research and write a dissertation
that covers a topic of sufficient scope and depth. During
this process, the scientist learns how to solve problems
from different perspectives. The scientist also collects
extensive data and performs data analyses, thereby
gaining valuable insight into the considerations necessary to determine the feasibility of collecting data in a
clinical trial. Also, some scientists, such as pharmacokineticists with a pharmacy background, may receive
some clinical experience during their training as a
scientist.
Scientists help design major portions of study protocols
and clinical case report forms (CRFs). The study protocol
is the overall plan that the study follows, and it must
contain certain types of information, including the
following: 1) background data on the targeted disease;
2) the empirical and structural formula of the drug being

129

studied; 3) preliminary pharmacology and toxicology of

the drug (specific study objectives and designs); 4) the
methods and materials to be used in the study;
5 ) information regarding drug packaging, labeling, dosage
forms, and decoding procedures; 6) overdose management; 7) patient discontinuation procedures; 8) explanation of informed consent and provisions regarding
institutional review board approval; and 9) any relevant
references and appendices. The CRFs are the forms on
which individual patient data are recorded during a clinical
trial. From these data, clinical and statistical analyses are
performed. All the information that is stipulated in the
study protocol must be collected on the CRFs.
In conjunction with nonscientific personnel, scientists
are responsible for ensuring that the CRFs will capture the
appropriate information for each study subject according
to the objectives, tests, and evaluations stipulated in the
protocol. Careful attention must be given to the
administration of special tests or collection of samples so
that the timing of the assessments or sample collections do
not conflict.
Experience in basic research enables the scientist to
function as an important link between the basic research
labs within the company and the drug development team.
Departments specializing in drug metabolism, microbiology, pharmacology, and toxicology need feedback
from early human safety and pharmacokinetic studies so
they can continue to plan and conduct appropriate longterm animal studies. Thus, communication between the
clinical scientist and the basic scientist is important
throughout the progress of the drug development
program.
Because clinical research has become increasingly
more scientific, experts in the methodology of science are
necessary for a complete research program. The drug
development teams scientists may account for much of
the scientific expertise, but the roles of the research team
overlap to form a scientifically sound, medically astute
cohesive group. In addition to scientific expertise, use of
the scientists administrative talents, such as organizational skills and familiarity with personnel practices,
enables effective drug development. Thus, scientists with
these skills are often employed in management positions in
many organizations.

armacists
The pharmacists role on the drug development team has
greatly expanded the professional opportunities of
individuals with backgrounds in pharmacy. Pharmacists
can provide valuable therapeutic insight into medical
research. Training of pharmacists as clinical scientists with

130

both clinical skills and scientific research skills continues

to be an emphasis at many pharmacy schools. Several
programs have been devised for the education and
development of the pharmacist as clinical scientist ( 2 ) .
Pharmacists have a broad knowledge in both clinical
medicine and pharmaceutics, and therefore are able to
bridge the gap between the clinic and the laboratory.
Pharmacists training focuses on drug therapies in
disease states, whereas physicians training focuses on the
diagnosis of disease states. Studies regarding drug
interaction, positive control, or drug comparison involve
drugs that have been studied and marketed. Pharmacists
can help in the design of such trials because of their
knowledge of marketed drugs.
Additional roles of pharmacists appear in the areas of
drug information and education and training. Pharmacists have the appropriate expertise in drug therapy to
answer inquiries from physicians (and other health
professionals) concerning both marketed and investigational drug products. Similarly, the clinic/laboratory
bridge that the pharmacist builds makes this team
member especially well suited to educate and train new
employees in drug development. By offering both
general and special skills, the research pharmacist
blends clinical medicine with pharmaceutical science
and is well qualified as an educator and drug information
specialist.

Drug development includes many tasks that may not

require the specialized expertise of a physician or a
scientist. Administrative skills, creativity, and excellent
communication abilities, which are qualities not necessarily emphasized within traditional medical and scientific
educational curricula, may be required for many of these
tasks.
The administrative skills necessary for drug development include incorporating seemingly disparate hut vitally
linked concepts into a single overall plan. Integration
planning may mean organizing study files into a logical
sequence or helping to assemble the various parts of an
NDA. In the first example, files must be set up in a way
that can facilitate internal quality assurance audits and
FDA inspections. In the second example, knowledge of the
FDAs regulations and good abstracting capabilities are
required.
Creativity is a quality that cannot be developed through
formal training. Creativity requires bold conjecture and it
expresses itself in newer, better ways to accomplish the
same goals. An example of creativity in clinical drug
research might involve the development of a variable

Clinical Evaluation of Drugs

report that could support all of the different research

documents that are generated by drug research teams.
With such a variable report, common information need not
be recreated each time another document is generated.
Excellent communication skills may be the most
important quality for individuals working in drug
development, even for those with strong medical backgrounds. Clinical research requires extensive interactions
with personnel within the organization and with outside
vendors or clinical sites. The information flow must be
both efficient and accurate. For example, marketing
departments must communicate frequently with medical
departments so that marketing studies, advertising. and
package inserts can be planned and evaluated. Individuals
who lack strong science backgrounds but who have
excellent communication skills often act as liaisons in
these situations.
One aspect of clinical research that requires extensive
contribution by the drug development team personnel is
study monitoring. Study monitors oversee the planning,
initiation, conduct. and data processing of clinical studies
(3). While monitoring studies, monitors must communicate frequently with investigators and help ensure the
data are being collected properly, FDA regulations are
being followed, and any administrative problems are
resolved as quickly as possible. Although monitors
traditionally have had a nonscientific background, many
monitors today have training in the basic sciences, and
some even have advanced degrees, which allows them to
better understand the scientific aspects of the project.
Effective study monitors have a wide range of talents.
The many facets of a clinical research program afford
individuals with varying types of training, education, and
experience, the opportunity to contribute to the drug
development process. Although some tasks clearly require
the clinical or scientific expertise of a physician or a
scientist, other tasks are better suited to those individuals
with less specialized and more general capabilities.

Before clinical drug development can begin, many years

of preclinical development occur, millions of dollars are
spent, and countless decisions are made. Basic research
teams consisting of chemists. pharmacologists, hiologists, and biochemists first identify promising therapeutic categories and classes of compounds. One or
more compounds are selected for secondary pharmacology evaluations and for both acute and subchronic
toxicology testing in animal models. A compound that is

Clinical ~ ~ a ~ u a t of
i oDrugs
n

pharmacologically active and safe in at least two

nonhuman species may then be selected for study in
humans. Before the drug can be tested in humans, an
Investigational New Drug (IND) application, which
contains supporting preclinical information and the
proposed clinical study designs, must be filed with an
appropriate regulatory agency.
Clinical drug development follows a sequential
process. By convention. development of a new drug in
humans is divided into four phases: preapproval segments
(Phases 1 through 3j and a postapproval segment (Phase 4)
(1-4). The definitions of the three preapproval phases
have relatively clear separations. However, the different
phases refer to different types of studies rather than a
specific time course of studies. For example. bioequivalence studies and drug-drug interaction studies are
both Phase 1 studies, but they may be conducted after
Phase 3 studies have been initiated. The generalized
sequence of studies may be tailored to each new drug
during development.

ase
After the appropriate regulatory agency has approved a
potential drug for testing in humans, Phase 1 of the clinical
program begins. The primary goal of Phase 1 studies is to
demonstrate safety in humans and to collect sufficient
pharmacokinetic and pharmacological information to
permit the determination of the dose strength and regimen
for Phase 2 studies.
Phase 1 studies are closely monitored, are typically
conducted in healthy adult subjects, and are designed to
meet the primary goal (i.e., to obtain information on the
safety, pharmacokinetics, and pharmacologic effects of the
drug). In addition. the metabolic profile, adverse events
associated with increasing dosages, and evidence of
efficacy may be obtained. Because most compounds are
available for initial studies as an oral formulation, the
initial pharm-acokinetic profile usually includes information about absorption. Additional studies, such as
drug-drug interactions. assessment of bioequivalence of
various formulations, or other studies that involve normal
subjects, are included in Phase 1.
Generally, the first study in humans is a rising,
single-dose tolerance study. The initial dose may be
based on animal pharmacology or toxicology data, such
as 10% of the no-effect dose. Doses are increased
gradually according to a predetermined scheme, often
some modification of the Fibonacci dose escalation
scheme ( 5 ) , until an adverse event is observed that
satisfies the predetermined criteria of a maximum
tolerated dose (MTD). Although the primary objective

131

is the determination of acute safety in humans, the

studies are designed to collect meaningful pharmacokinetic information. Efficacy information or surrogate
efficacy measurements also may be collected. However,
because a multitude of clinical measurements and tests
must be performed to assess safety, measurements of
efficacy parameters must not compromise the collection
of safety and pharmacokinetic data.
Appropriate biological samples for pharmacokinetic
assessment, typically blood and urine. should be
collected at discrete time intervals based upon extrapolations from the pharmacokinetics of the drug in animals.
Depending on the assay sensitivity, the half-life and
other pharmacokinetic parameters in healthy volunteers
should be able to be evaluated, particularly at the higher
doses. The degree of exposure of the drug is an
important factor in understanding the toxicologic results
of the study. Pharmacokinetic linearity (dose linearity) or
nonlinearity will be an important factor in the design of
future studies.
Once the initial dose has been determined, a placebocontrolled, double-blind, escalating single-dose study is
initiated. Generally, healthy male volunteers are
recruited, although patients sometimes are used (e.g.,
when testing a potential anticancer drug that may be too
toxic to administer to healthy volunteers). These studies
may include two or three cohorts, with six or eight
subjects receiving the active drug and two subjects
receiving placebo. The groups may receive alternating
dose levels, which allow assessment of dose linearity,
intrasubject variability of pharmacokinetics, and doseresponse (i.e., adverse events) relationship within
individual subjects.
Participants in the first study are usually hospitalized or
enrolled in a clinic so that clinical measurements can be
performed under controlled conditions and any medical
emergency can be handled in the most expeditious
manner. This study is usually placebo-controlled and
double-blinded so that the drug effects, such as druginduced ataxia, can be distinguished from the nondrug
effects, such as ataxia secondary to viral infection. The
first study in humans is usually not considered successfully
completed until an MTD has been reached. An MTD must
be reached because the relationship between a clinical
event (e.g., emesis) and a particular dose level observed
under controlled conditions can provide information that
will be extremely useful when designing future trials.
Also, the dose range and route of administration should be
established during Phase 1 studies.
A multiple-dose safety study typically is initiated once
the first study in humans is completed. The primary goal
of the second study is to define an MTD with multiple

Clinical Evaluation of Drugs

132

dosing before to initiating well-controlled efficacy testing.

The study design of the multiple-dose safety study should
simulate actual clinical conditions in as many ways as
possible; however, scientific and statistical validity must
be maintained. The inclusion of a placebo group is
essential to allow the determination of drug-related versus
nondrug-related events. The dosing schedule, which
includes dosages, frequency, dose escalations, and dose
tapering, should simulate the regimen to be followed in
efficacy testing.
Typically, dosing in the second study lasts for 2 weeks.
The length of the study may be increased depending on the
pharmacokinetics of the drug so that both drug and
metabolite concentrations reach steady state. Also, if the
drug is to be used to treat a chronic condition, a 4-week
study duration may be appropriate. To obtain information
for six dose levels with six subjects receiving active drug
and two receiving placebo for each of two cohorts, a
minimum enrollment of 24 subjects should be anticipated.
Similar to the first study in humans, these subjects would
be hospitalized for the duration of the study.
Also similar to the first study, pharmacokinetic data
must be obtained. These data will be used to help determine
dosage in future efficacy trials. The new pharmacokinetic
information that can be gathered includes the following:
1) determination regarding whether the pharmacokinetic
parameters obtained in the previous acute safety study
accurately predicted the multiple dose pharmacokinetic
behavior of the drug; 2) verification of pharmacokinetic
linearity (i.e., dose proportionality of C,,
and AUC)
observed in the acute study; 3) determination regarding
whether the drug is subject to autoinduction of clearance
upon multidosing; and 4) determination of the existence
and accumulation of metabolites that could not be detected
in the previous single-dose study. A number of
experimental approaches can be used to gather this
information, and all require frequent collection of blood
and urine samples. The challenge to the clinical
pharmacokineticist is to design an appropriate blood
sample collection schedule that will maximize the
pharmacokinetic information, yet can be gathered without
biasing the primary objective-determination
of clinical
safety parameters.

After the initial introduction of a new drug into humans,

Phase 2 studies are conducted. The focus of these Phase 2
studies is on efficacy, while the pharmacokinetic
information obtained in Phase 1 studies is used to
optimize the dosage regimen. Phase 2 studies are not as
closely monitored as Phase 1 studies and are conducted in

patients. These studies are designed to obtain information

on the efficacy and pharmacologic effects of the drug, in
addition to the pharmacokinetics. Additional pharmacokinetic and pharmacologic information collected in Phase 2
studies may help to optimize the dose strength and
regimen and may provide additional information on the
drugs safety profile (e.g., determine potential drug-drug
interactions).
Efficacy trials should not to be initiated until the MTD
has been defined. In addition, the availability of
pharmacokinetic information in healthy volunteers is key
to the design of successful efficacy trials. The clinical
pharmacokineticist assists in the design and execution of
these trials and analyzes the plasma drug concentration
data upon completion of the efficacy studies.
During the planning stage of an efficacy trial, the focus
is on the dosage regimen and its relationship to efficacy
measurements. Plasma drug concentrations for various
dosages can be simulated based upon the data collected in
the first two studies in humans. The disease or
physiological states of the test patients (e.g., organ
dysfunction as a function of age), concurrent medications
(e.g., enzyme inducers or inhibitors), and the safety data
obtained earlier must be considered when choosing an
optimal dosage regimen for the study. In addition, if the
targeted site of the drug is in a tissue compartment,
theoretical drug levels in this compartment can be
simulated, which may help scientists determine the
appropriate times for efficacy measurements.
On completion of the efficacy trial, a therapeutic
window for plasma drug concentrations can be defined by
reviewing the correlation between plasma drug concentrations and key safety and efficacy parameters. The goal is
to improve efficacy and safety of the drug by
individualizing the dosage based upon previous plasma
drug concentration profiles in the same patient.

Phase 3
If the earlier clinical studies establish a drugs therapeutic,
clinical pharmacologic, and toxicologic properties and if it
is still considered to be a promising dmg-Phase 3 clinical
trials will be initiated. Phase 3 studies enroll many more
patients and may be conducted both in a hospital or
controlled setting and in general practice settings. The
goals of Phase 3 studies are to confirm the therapeutic
effect, establish dosage range and interval, and assess
long-term safety and toxicity. Less common side effects
and AEs that develop latently may be identified. In
addition, studies targeted to evaluate and quantify specific
effects of the drug, such as drowsiness or impaired
coordination, are conducted during this phase.

307

Economic Evaluations of Clinical Pharmacy Services (ACCP)

Appendix 1 Evaluations of economic value of clinical pharmacy services-1988Objective

(as stated
by authors)

Setting

Disease state management

To evaluate
CH"'
impact of
benzodiazepine
guidelines
on cost and
quality of care
of patients
hospitalized for
alcohol
withdrawal

Analytic Comparison
method
group

Input costs

1995

Outcomes
included

Results measured

Comments

OA

Control
group

None

DCA, LOS

Mean drug cost

decreased from
$1008/day to
$59/day/patient;
mean ICU LOS
decreased from
4.1 to 1.1 days

Input costs not

considered

UH[']

TO

evaluate
impact of
clinical RPh
on cost
savings and
patient
outcome in
asthma clinic

CBA

Historical
control

Cost of clinic
visit offset
other savings

cost of
emergency
room visits
for asthma
exacerbation

Cost savings
$30,693 and
$68,393 between
study period and
each of two
control
periods; savings
derived from
reduction in
ER visits

Drug costs not

considered;
economic value
of clinical
outcomes
(beyond
ER visits) not
assessed; no
ratio calculated

CHLgl

To evaluate
impact of
renal function
monitoring
program,
focusing on
appropriate
dosages
of renally
eliminated agents

COD

None

Personnel
costs

DCA

Cost savings
$5040 noted,
with program
cost $2700
for labor

No control group:
clinical outcomes
not considered:
measured only
what the cost of
therapy would
have been without
intervention

UACH"']

To conduct
time and
motion analysis
of PCA
vs. i.m. analgesia
and evaluate
impact on cost
and quality of
pain control

CBA

Historical
control

Costs of drug,
RPh, and
nursing labor

LOS, cost
of ADRs,
quality of
analgesia

Quality of analgesia
increased with PCA.
but so did cost
and time required

Evaluated both
RPh and nursing
time: did not
provide ratio

None

Personnel costs DCA, type of Cost savings of

$1.98/$1 invested,
intervention
with total annual
savings $7100

General pharmacotherapeutic monitoring

UH['']
TO examine cost
COD
benefit of
clinical pharmacy
intervention and
documentation
system

Missing relevant
costs and outcomes

(Continued)

308

Economic Evaluations of Clinical Pharmacy Services (ACCP)

Appendix I

Setting

Evaluations of economic value of clinical pharmacy services-1988 - 1995 (Continued)

Objective
(as stated
Analytic Comparison
Outcomes
group
Input costs
included
Results measured
by authors)
method
OD
DCA, LOS
None
To assess the
None
Positive impact on
quality and cost
patient care,
avoidance of RPh
estimated reduced
interventions
LOS by 3.7 days
using physician
assessors

Comments
Physician reviewers
estimated reduction
in LOS resulting
from interventions

To cost justify
clinical pharmacy
service on
general surgery
team
To study effect
of clinical RPh
on health care
outcomes

COD

None

Personnel
costs

DCA, type of
intervention,
clinical impact
of intervention

Positive impact on Small sample

outcomes; net
cost avoidance of
$441.46/patient

CBA

Control
group

Personnel
costs

LOS, drug
costs/
admission

Average net
savings
$377/patient
admission;
cost : benefit
ratio 4.03 : 1

To measure impact
of pharmaceutical
services on overall
health care costs,
and to estimate RPh
productivity

COD

None

Personnel
costs,
direct costs,
overhead

Percentage of
problematic
drugs, use
of service,
DCA

Average total
cost savings
$444/patient;
cost : benefit
ratio 3.2 : 1

To evaluate clinical
RPh recommendations
on number and costs
of drugs

OD

Control
group

None

DCA

Decreased
average
monthly drug
cosupatient

Input costs not

considered

To describe program
and determine
cost savings from
clinical pharmacy
services provided in
rehabilitation clinic

OD

None

None

DCA

Reduced hospital
drug costs by
$2700 during
6-mo study

Input costs not

considered

To evaluate clinical
pharmacy services
and determine
cost savings and
justification for
additional pharmacy
staff

COD

None

Personnel
costs

DCA

Annual net
savings $25,862

To evaluate impact
of a clinical
coordinator on
costs avoided by
the institution
from clinical
clinical intervention
program

OA

Pre/post

None

DCA, NO1

Average monthly
net savings $3739
and $4644 before
and after clinical
coordinator

Control group
included

(Continued)

Economic Evaluations of Clinical Pharmacy Services (ACCP)

309

Appendix 1 Evaluations of economic value of clinical pharmacy services-1988

Setting

Objective
(as stated
by authors)

Analytic
method

Comparison
group
Input costs

- 1995

(Continued)

Outcomes
included

Results measured

Comments

To describe
interventions
made by clinical
RPh and evaluate
cost savings and
cost avoidance
impact

COD

None

Personnel
costs

DCA, NO1

Cost savings of
$69.1 lipatient-day;
annual net savings
$300,079

To compare cost
and quality of
decentralized vs.
centralized
pharmaceutical
services

OA

Pre/post

None

LOS, total
cost/admission

Decreased average
total cost/admission
by $1293; decreased
average pharmacy
cosUadmission by
$155 for
decentralized

To examine value
of clinical pharmacy
intervention
program in a
community
pharmacy setting
and determine
economic value

OD

None

None

DCA, NO1

Cost avoided of
$3.47/prescription
processed

To describe
program to
develop clinical
pharmacy staff
and determine
cost avoidance to
hospital resulting
from the service

OD

None

None

DCA

Average estimated
cost avoidance
$9306/mo over 5 yrs

To evaluate and
document impact
of clinical RPh on
costs avoided at
tertiary care
teaching hospital

COD

None

Personnel
costs

DCA

Net annualized cost

avoidance $897,350

To evaluate impact
of clinical RPh on
cost and quality of
patient care in
ambulatory care
clinics

COD

None

Personnel
costs

DCA

Net annualized cost

avoidance $221,056

Emphasized
need for
documenting
interventions

To evaluate
impact of
clinical RPh on
medical team

OD

None

None

Interventions
documented

27% of interventions
prevented serious
effects

Input costs not

considered

Input costs not

considered

(Continued)

Economic Evaluations of Clinical Pharmacy Services (ACCP)

310

Appendix 1 Evaluations of economic value of clinical pharmacy services-1988-

1995 (Continued)

Setting

Objective
(as stated
by authors)

Analytic Comparison
method
group

Input costs

Outcomes
included

esults measured

Comments

To evaluate impact
of reactive clinical
pharmacy
interventions on
cost and quality
of patient care

OD

None

None

Cost impact of 2.9% of pharmacy

interventions
interventions
prevented potential
documented
medical harm;
limited cost impact

Input costs not

considered;
physicians
assessed RPh
service,
introducing
potential bias

To evaluate daily
data collection of
decentralized
clinical pharmacy
services

OD

None

None

DCA

Total savings
$126,504 due to
2506 interventions
provided

Input costs not

considered;
clinical outcomes
not considered;
no comparative
group used to
assess cost
and outcome
difference

CBA

Control
group

Personnel
costs

cost
avoidance
due to
reduced
number of
prescriptions

Cost avoidance
$4.63 for
intervention
group vs. $1.10
in control group;
savings in
prescription filling
labor noted; labor
costs associated
with program
offset by DCA

Clinical outcomes
not considered; no
ratio presented

OD

None

None

cost
avoidance
in drug and
laboratory
use

$19,000 in cost
reduction for
interventions.
184 patients;
documented
clinical outcomes
after interventions

Discussed cost
of personnel
required for
program, but did
not factor cost
into analysis; no
comparison group
for analysis

GAAC[311 To evaluate impact

(VA)
of clinical RPh on
cost and quality
of patient care

CBA

Pre/post

Costs
DCA
associated
with program
and dispensing
prescriptions
generated in
the clinic

Total cost decrease

of $22,241 during
study period

Charts assessed
for quality based
on the rate of
suggestion
implementation,
but actual patient
outcomes not
assessed

UACH[321 To evaluate cost

impact of clinical
RPh in intensive
care unit

COD

None

Personnel
costs

Cost savings
$10,010 (Canadian)
documented over
3-mo study period;
cost:benefit
ratio 4 : 1

No control group;
measured only
what the cost
of therapy would
have been without
intervention

GAAC[291 To evaluate
impact of clinical
RPhs interventions
on physician
prescribing and
costs in an
ambulatory clinic

UAAC[]

To evaluate impact
of ambulatory
clinical pharmacy
program and to
justify personnel
for the program

DCA

(Continued)

Economic Evaluations of Clinical Pharmacy Services (ACCP)

311

ADwendix 1 Evaluations of economic value of clinical oharmacv services-1988

Setting

Objective
(as stated
by authors)

Analytic
method

Comparison
group

Input costs

- 1995

Outcomes
included

iContinued)

Results measured

Comments

To evaluate
impact of
pharmacy
faculty providing
clinical pharmacy
interventions on
drug costs and
pharmacy
department
revenue

OD

None

None

DCA and
service
revenue
generated

Impact of 278
interventions
evaluated.
demonstrating
drug cost
avoidance
$1661, generation
of $6000 in
revenue from
pharmacokinetic
consultations

No control group;
measured only
what the cost of
therapy would
have been without
intervention

To evaluate
impact of
clinical RPh on
drug prescribing
and cost savings

CBA

Control
group

Personnel
costs

DCA

Decreased total
number of
prescriptions and
associated ADRs;
total cost of
prescriptions filled
in study period
$3872 less than
during control
period; total cost
to administer
program S2250

No ratio
presented;
mentioned but
did not quantify
value of
prevented ADRs

CH[35]

To evaluate
impact of
documentation
system for
clinical pharmacy
services

OD

None

None

DCA

Cost avoidance
ranged $2341 $7762/quarter
during study

Input costs not

considered; no
control group;
clinical outcomes
not considered

~ ~ " 6 1

To evaluate cost
impact of
implementing
clinical pharmacy
services in
intensive care
unit

COD

None

Personnel
costs

DCA

During 32 days,
cost avoidance
$1651, labor cost
associated with
program was
$2599

To evaluate
acceptance and
cost savings
resulting from
2-yr
postbaccalaureate
PharmD student
interventions

OD

None

None

NOI, DCA,
laboratory
cost
avoidance

Estimated annual
drug savings
$3891

No control group;
clinical outcomes
not considered;
small sample size
(number of pilot
days assessed,
and short
period of
timeiday)
Input costs not
considered

(Continued)

Economic Evaluations of Clinical Pharmacy Services (ACCP)

312

Appendix 1 Evaluations of economic value of clinical pharmacy services-1988

Setting

Objective
(as stated
by authors)

Analytic
method

Comparison
group

Input costs

- 1995

(Continued)

0utcomes
included

Results measured

Comments

To determine cost
savings of clinical
pharmacy service
in a community
hospital

CD

None

Personnel
costs

DCA

Savings of
$1,49/patient/day
for clinical
pharmacy services

Brief description
of daily
documentation
activity to
demonstrate
cost savings

To describe
impact of general
clinical pharmacy
interventions on
hospital costs

OD

None

None

Physician
acceptance,
NOI, DCA

Total savings
$15,525.81

Input costs not

considered

To evaluate
impact of
comprehensive
clinical pharmacy
services on
hospital costs
To evaluate
impact of clinical
pharmacy service
on hospital costs
using cost-benefit
analysis

OA

Prelpost

None

DCA

Net cost savings

$34.10/RPh-day

Input costs not

considered;
clinical
outcomes not
considered

CBA

Historical
control

Cost of
providing
service

DCA

Cost:benefit ratios
1.08 and 1.59 for
2 ward-based
groups

Clinical
outcomes not
considered

To determine
impact of clinical
interventions on
cost and quality
of patient care

OD

None

None

Number of
inappropriate
laboratory tests,
DCA

Annual drug cost

avoidance of
$26,580

To evaluate
impact of
PharmD student
interventions

OD

None

None

NOI, physician
acceptance

Decreased drug
costs by 50.7%

To document
interventions
of clinical RPh
in emergency
department

OA

Prelpost

None

DCA

Description of
clinical and
cost-saving
interventions

Input costs not

considered;
clinical
outcomes not
considered

To evaluate
impact of clinical
pharmacy
interventions on
cost and quality
of patient care

COD

None

Personnel
costs

Physician
acceptance,
DCA, various
quality
indicators

Annual
extrapolated
cost savings
$19,076

Documented cost
and quality using
daily patient data
collection forms

To determine
impact of clinical
RPh on cost
savings to the
hospital and
quality of
patient care

OA

Control
group

None

NOI, DCA

RPhs saved
$176,724
annually

Extrapolated
savings
from 2-wk pilot

(Continued)

Economic Evaluations of Clinical Pharmacy Services (ACCP)

313

Appendix 1 Evaluations of economic value of clinical pharmacy services-1988 - 1995 (Continued)

Setting

cp"v

Objective
(as stated
by authors)

Analytic Comparison
method
group

Input costs

Outcomes
included

Results measured

Comments

To evaluate
cost savings to
pharmacy from
interventions of
community RPh

OD

None

None

Assessment of
value of RPh
interventions,
cost of medical
care avoided

Value of avoided
care was $122.98/
intervention: $2.32
savings/prescription
screened

UAAC[481 To evaluate
impact of
clinical RPh on
cost and quality
of patient care

OD

None

None

Physician
acceptance,
patient outcome
indicators, DCA

205 interventions
made during 6-mo
study: 80.9% made
to increase quality:
18.1% to increase
quality and
decrease cost

None

None

Unnecessary
samples,
patient charges

Charge avoidance
$500,000 annually

Input costs not

considered;
charges vs. costs

DCA, number
of drug assays

Increased number
of drug levels
ordered; decrease
of $599 in
hospital costs

Increased
rational
ordering of
serum drug
concentrations

Pharmacokinetic monitoring service

To determine effect
OD
of TDM program
on inappropriate
sampling times
To evaluate
impact of
educational
efforts on use
of SDCs

OA

Pre/post

None

To determine
cost benefit of
pharmacokinetic
services for
patients receiving
aminoglycosides

CBA

Control
group

Variable costs, LOS, clinical

personnel costs, response
fixed costs

Decreased LOS:
decreased duration
of febrile period:
benefit:cost ratio
75.84:l and
52.25: 1

To determine
physician
acceptance and
impact of clinical
pharmacokinetic
recommendations
on cost and quality
of patient care

CBA

Control
group

Variable costs, Acceptance by

personnel costs, physicians,
LOS, DCA,
fixed costs
clinical response

Decreased LOS;
decreased febrile
period; decreased
direct costs; cost
of service
$85/patient

To evaluate impact
of clinical
pharmacokinetic
service on cost
and quality of
patient care
To evaluate
costs associated
with clinical
pharmacokinetic
dosing service

CBA

Control
group

Variable costs,
fixed costs

LOS, clinical
response,
patient charges

Decreased length
of treatment;
decreased LOS;
annual cost
savings $113,934

Used charges
rather than costs

OA

Pre/post

None

LOS, DCA

Cost reduction
$107,000
associated with
decrease in LOS:
reduction of
$14,000 in drug
costs associated
with program

Mentioned but
did not value
cost of system

(Continued)

Economic Evaluations of Clinical Pharmacy Services (ACCP)

314

Append~x1 Evaluations of economic value of clinical pharmacy services-1988 - 1995 (Continued)

Objective
(as stated
by authors)

Analytic
method

Comparison
group

CBA

Historical
control

Personnel
costs

cost of
laboratory
testing avoided

Increased
appropriateness
of serum drug
concentration
determination;
cost of $1000
with savings of
$3000

Clinical
outcomes not
considered; no
ratio presented

U H [ ~ TO
~ ~evaluate impact
of pediatric
pharmacokinetic
service using
guidelines as basis
for appropriate
monitoring

CA

Control
group

None

Costs avoided
through decrease
in inappropriate
monitoring

Annual cost
avoidance
$12,325 based
on fewer
inappropriate
laboratory
assays

Input costs not

considered

CHL571 To evaluate
effectiveness of
serum digoxin
concentration
monitoring, and
determine cost
impact of service

OD

None

None

NOI, timing of
digoxin serum
concentrations,
laboratory costs
avoided

Decreased
number
of digoxin
serum drug
concentrations
ordered

Input costs not

considered

OA

Control
group

None

Number and cost

of drug assays,
LOS and
readmission rate

Overall cost
savings after
1 yr of program
$100.00

Charges vs. costs

UH591 To evaluate impact

of therapeutic drug
monitoring program
for theophylline

OA

Control
group

None

Number and
cost of drug
assays, LOS

Equal cost of
RPh monitoring
and savings
after 1 yr

Charges vs. costs

UH[~]

CBA

Control
group

Service cost

LOS, room
charge, DCA

$13 11 savings/
patient in study
group; CBA
ratio of 4.09 : 1
in favor of
study group

Used charges
rather than
costs

OA

Control
group

None

LOS. room
charges, cost
of concomitant
drugs

Decreased LOS
of 1.96 days;
$490 savings/
patient in
study groups

Used charges
rather than
costs

PrePost

None

DCA

15% reduction
in amount of
ondansetron
dispensed
from period
before guideline
implementation

Input costs not

considered;
clinical
outcomes not
considered

Setting
UHL5

UHL5

To evaluate impact
of clinical RPh on
appropriate serum
drug concentration
ordering

To analyze need
for therapeutic
drug monitoring
program for
phenytoin

evaluate
impact of
computer-assisted
aminoglycoside
dosing

TO

CHL611 To compare RPh

vs. physician
dosing of
aminophylline

Target drug programs: Antiemetic agents

UHL6*] TO evaluate impact
OA
of prescribing
guidelines for use
of ondansetron on
drug costs

Input costs

Outcomes
included

Results measured

Comments

(Continued)

Economic Evaluations of Clinical Pharmacy Services (ACCP)

315

Appendix 1 Evaluations of economic value of clinical pharmacy services-1988

Setting

Objective
(as stated
by authors)

Analytic
method

Target drug programs: Antihypertensives

HMOC[631 To evaluate impact
OA
of clinical RPh
consultation on cost
of antihypertensive
therapy in HMO
family practice
clinic
Target drug programs: Antimicrobials
UAAC[64' To assess impact
OA
of fluconazole
guidelines and
concurrent RPh
intervention

Comparison
group
Input costs

- 1995

(Continued)

Outcomes
included

Results measured

Comments

Control
group

None

Average daily
drug costs

Decreased drug
costs of $20.61/
patient-year

Input costs not

considered

Historical
control

None

Appropriate
use, ADRs,
DCA

Annual cost
avoidance
$65,520

Input costs not

considered

To describe
experience with
program for
modifying dosing
regimens of
mezlocillin

OD

None

None

DCA

Annual cost
savings
$33,000 or
$49.47/patient

Input costs not

considered

To document cost
containment of
RPh antibiotic
streamlining
program

OD

None

None

DCA

Annual cost
savings $47,700

Input costs not

considered

To evaluate
educational and
intervention
program promoting
use of metronidazole
for antibioticassociated colitis

OD

Historical
control

None

DCA

Estimated annual
savings $38,829
based on
decreased
drug costs

Input costs not

considered;
clinical
outcomes not
considered

To evaluate impact
of therapeutic
intervention to
alter metronidazole
dosing

COD

Prelpo st

Personnel
costs

DCA

Annual savings
$28,000

Input costs
not considered

To describe antibiotic
monitoring program
and determine costs
avoided to hospital
from rational
antibiotic use

OD

None

None

DCA,
appropriateness

Total cost
avoidance
$42,512 during
study period

Input costs not

considered

To evaluate impact
of target drug
monitoring program
for clindamycin on
hospital costs

OA

Historical
control

None

DCA

Cost avoidance
$16,000 annually

Input costs not

considered

(Continued)

Economic Evaluations of Clinical Pharmacy Services (ACCP)

316

Appendix 1 Evaluations of economic value of clinical pharmacy services-1988

Objective
(as stated
by authors)

Setting

Analytic
method

Comparison
group
Input costs

- 1995 (Continued)

Outcomes
included

Results measured

Comments

To evaluate impact
of clinical RPh
monitoring on i.v.
ceftriaxone use
(conversion to
oral cefpodoxime)
To evaluate
antimicrobial
management
program and
evaluate impact
on cost and
quality of
patient care

CBA

Control
group

cost of
treatment

cost of
treatment
outcome

Cost savings
S46.0Ypatient
achieved, I-day
decrease in LOS

Input costs not

considered; small
sample

OA

Historical
control

None

DCA

Gross savings
in antibiotic
acquisition
cost $483,032/yr

Cost associated
with service
considered, but
not quantified

To evaluate cost
impact of two
DUE activities
performed by
undergraduate
pharmacy students

OD

Historical
control

None

DCA

Cefazolin dosing
modification
(q6h to q8h)
resulted in savings
of 518,000;
substitution of
metronidazole for
clindamycin saved
s21,000

Input costs not

considered;
clinical outcomes
not considered

To evaluate cost
impact of
pharmacy-based
antibiotic
optimization
program
GH[751
To evaluate impact
(State)
of RPh participating
in patient care
rounds on costs
associated with
antimicrobial
drug use
UACH[761 To evaluate
impact of clinical
RPh-based antibiotic
management
program

OA

Prelpost

None

DCA

Savings of
$12,640 realized
after program
implementation

Input costs not

considered;
clinical outcomes
not considered

OA

Pre/po st

None

DCA

Cost reduction
of $29,800
greater in study
period vs.
prestudy period

Input costs not

considered

OA

Control
group

None

Drug and
ancillary cost
avoidance

Estimated cost
savings $40,000
associated with
drug cost
avoidance and
appropriate use
of laboratory data

Input costs not

considered;
clinical outcomes
not considered

UACHK7] To evaluate impact

of renal function
monitoring program,
focusing on
appropriate dosages
of imipenem

OD

None

None

DCA

Potential to save
$1 1,500 annually
by adjusting
imipenem dosages
on basis of renal
function

Input costs not

considered; no
control group;
clinical outcomes
not considered

GHL711
(VA)

UHL7

UH[741

(Coiztiizued)

Economic Evaluations of Clinical Pharmacy Services (ACCP)

317

Appendix 1 Evaluations of economic value of clinical pharmacy services-1 988 - 1995 (Continued)

Setting

Objective
(as stated
by authors)

Analytical Comparison
method
group

Input costs

Outcomes
included

Results measured

Comments

Predicted cost
avoidance
approximately
$80,000 in control
vs. study periods,
but actual cost
reduction attributed
to program
>$200,000

Cost associated
with providing
program
mentioned but
not quantified

UACH[7X1 To evaluate cost

impact of
computerized
antibiotic
monitoring
program

OA

Historical
control

None

UH7g1

To evaluate impact
on hospital costs of
antibiotic program
using education
and antimicrobial
restriction

CBA

Prelpost

Costs of drug, LOS. infection

labor, and
frequency
program
monitoring and
implementation

Cost savings
$14,250
annually with
quality of
care remaining
constant

No ratio
presented

MC.
UH[*]

To conduct
retrospective
DUE to determine
potential cost
savings of
ceftazidime
dosage adjustment

OD

None

None

DCA

Ceftazidime
dosing in elderly
found to be in
excess of labeled
dosing because
renal function
not considered

Input costs not

considered;
clinical
outcomes
not considered

UHL8

TO evaluate impact
of clinical RPhs
intervention on
antibiotic costs

OA

Pre/post

None

LOS, DCA

Audit results 3
mo before and
after intervention
revealed $3498.40
reduction in drug
costs

UH[*]

To determine impact
of antibiotic
monitoring program

CBA

Pre/post

Cost of
printing
intervention
form

DCA

Net savings
$17,000
annually

Clinical
outcomes not
considered;
personnel costs
not considered;
no ratio
presented

UAGH[

TO evaluate impact
of compliance with
guidelines for thirdgeneration
cephalosporins

OA

Prelpost

None

Clinical and
microbiologic
indicators;
DCA

Documented
reduction of
$27,000 over
6 mo in pharmacy
expenditure for
antibiotics

Input costs not

considered

OD

None

None

Clinical and
microbiologic
indicators,
laboratory
costs, DCA

Savings $38;920
over 7 mo;
projected annual
savings $107,000

Input costs not

considered;
assumed quality
and clinical
outcome to
be equal

UACH[S41 To evaluate impact

of antimicrobial
intervention
program

DCA

(Conrinued)

Economic Evaluations of Clinical Pharmacy Services (ACCP)

318

Appendix 1 Evaluations of economic value of clinical pharmacy services-1988-

Setting

Objective
(as stated
by authors)

Analytical Comparison
method
group
Input costs

Outcomes
included

Results measured

Comments

To evaluate impact
of antibiotic policy
on hospital costs
and quality of
patient care

OA

Prelpost

None

DCA, duration
of antibiotics,
LOS, mortality

Decreased monthly
antibiotic costs by
$7600; average
savings $91,200
annually; fewer
deaths; decreased
LOS

To describe cost
savings to hospital
resulting from
clinical RPh and
nursing antibiotic
prescribing
interventions

OD

None

None

DCA, NO1

Cost avoidance
$23,993 during
study period

To describe and
evaluate dosing
intervention
program for
imipenem

OA

Prelpost

None

ADRs, DCA

Decreased number Retrospective

of seizure episodes; chart review
cost savings due to
dosage change

To evaluate impact
of concurrent
antibiotic use
program

OA

Prelpost

None

Length of
antibiotic therapy
mortality, DCA,
pharmacy cost,
nursing cost

Decreased number
of antibiotic
dosedpatient
by 24%: 32%
reduction in drug
costs

Input
costs not
considered

To conduct DUE
of prophylactic
antibiotic therapy
and determine
cost savings to
hospital

OA

Prelpost

None

DCA, number
of inappropriate
orders

Projected annual
cost savings
$25,000

Input
costs not
considered

OA

Prelpost

None

Efficacy
indicators,
ADRs. DCA

Decreased cost of
daily antibiotic
therapy in
study group

Input
costs not
considered

None

Personnel
DCA
costs, direct
costs

Cost avoidance
range $606-8668
annually

No control
group

None

Decreased hospital
costlpatient
treatment day by
33% equal to
$8053/yr

UACHr901 To evaluate impact

of antibiotic
therapeutic
interchange
program

Target drug programs: Acid-reduction therapy

CHi911
To document
COD
inappropriate use
of i.v. H2RAs and
calculate cost
avoided with oral
conversion
CH[921

1995 (Continued)

To describe and
evaluate the
development of
renal dosing
intervention strategy
for intermittent
i.v. HzRAs

OA

Prelpost

DCA

Input
costs not
considered

(Continued)

Economic Evaluations of Clinical Pharmacy Services (ACCP)

319

Appendix 1 Evaluations of economic value of clinical pharmacy services-1988 - 1995 (Continued)

Setting

Objective
(as stated
by authors)

Analytical Comparison
method
group
Input costs

To evaluate cost
savings to hospital
resulting from
clinical RPh
recommendations
for dosing i.v.
H~RAs

OA

To evaluate impact
of educational
intervention
with guideline
implementation

CBA

To evaluate
impact of
concurrent
DUE program
on costs
associated with
acid-reducing
therapy

Outcomes
included

Results measured

Comments

None

DCA

Treatment cost
decreased by
$1.27/day; annual
savings $838

Input costs not

considered;
clinical
outcomes not
considered

Prelpost

Personnel
costs

DCA

Annual cost
avoidance of
$25,000 associated
with decreased use
of acid-reducing
therapy; estimated
cost of program
$3000

Clinical
outcomes not
considered; no
ratio presented

OA

Prelpost

None

DCA; clinical
outcomes
including
antacid use and
ordering of
gastro-intestinal
tests

Cost avoidance of
$327,273 attributed
to program, with
no significant
increase in
antacid use of
number of upper
gastrointestinal
studies

Input costs not

considered

To evaluate
cost impact
of program
authorizing
clinical RPh
conversion
of drugs from
parenteral to
oral route

OA

Control
group

None

DCA

Cost avoidance
$53,950 with
decrease in length
of parenteral
therapy

Clinical
outcomes not
considered;
mentioned but
did not quantify
labor cost
associated with
program;
mentioned
but did not
calculate ratio

To evaluate impact
of guideline-based
intervention
program on
cost of H2RA
therapy

OD

None

None

DCA

Total cost
avoidance
$47,672
during first
6 mo

Input costs not

considered; no
control group;
clinical
outcomes not
considered

To evaluate impact
of clinical RPh
intervention
program on cost
of H2RA therapy

CBA

Prelpost

Personnel
costs

DCA

Annual savings
$14,600, with labor
costs of $3400;
calculated cost :
benefit ratio 4.3 : 1

Clinical
outcomes not
considered;
useful model for
justification of
program provided
outcomes
considered

Prelpost

(Conrinued)

Economic Evaluations of Clinical Pharmacy Services (ACCP)

320

Appendix 1 Evaluations of economic value of clinical pharmacy services-1988-

Setting

bjective
(as stated
by authors)

Analytical Comparison
method
group
Input costs

1995 (Continued)

Outcomes
included

Results measured

Comments

CH[99]

To elaluate cost
impact of
therapeutic
interchange
program for
H2RA therapy

OD

None

None

Drug and ancillary Estimated cost

cost avoidance
avoidance
$37,565lyr

Input costs not

considered; no
control group;
clinical outcomes
not considered;
included sunk
costs (nursing
costs associated
with additional
doses of drug)
as costs avoided

CH""]

To evaluate
impact of
therapeutic
interchange
program for
H2RA therapy

OD

None

None

DCA

Total $145,557 in
cost avoidance in
first yr of program

Input costs not

considered; no
control group;
clinical outcomes
not considered

HMOC"~']

TO evaluate
cost impact
of educational
interventions
in improving
use of H2RA
therapy

OA

Prelpost

None

DCA

Input costs not

Study group had
fewer prescriptions, considered:
clinical outcomes
less expensive
not considered;
prescriptions, and
small sample
more appropriate
(number of
prescriptions after
prescribers
educational
involved in
interventions than
intervention)
control group

OD

None

None

DCA. ADRs.
assessment of
treatment failure

Estimated annual
cost savings
$16.000: reduced
parenteral H2RA
use

UACH"021 To describe
impact of
therapeutic
interchange
program for
H2RAs on
cost and
quality of
patient care
UH['O3]

To evaluate
impact of
ranitidine i.v.
to oral
conversion
project on
cost savings
to hospital

OD

None

None

DCA

Decreased number
of days of i.v.
acid-reducing
agents: annual
savings $23,425

CH[''~]

TO

evaluate
impact of
clinical RPh
monitoring and
intervention
program on i.v.
H2RA therapy

CBA

Control
group

Personnel
costs

Number of i.v.
doses and
days of i.v. drug,
DCA

Lower mean
number of
inappropriate
doses in
study group;
projected net
annual savings
$15,766.37

Retrospective
analysis; no
evidence of
increased
treatment failure
or adverse
patient outcome

No ratio
presented

(Continued)

Economic Evaluations of Clinical Pharmacy Services (ACCP)

321

Appendix 1 Evaluations of economic value of clinical pharmacy services--1988

Objective
(as stated
by authors)

Setting

Analytical Comparison
method
group
Input costs

~~~~

(Continued)

Outcomes
included

Results measured

Comments

To conduct
prospective cost
analysis of
educational
efforts to change
inappropriate
prescribing of
H2RAs

OA

Prelpost

None

Physician
prescribing pattern,
DCA, number of
drug interactions

Savings of
$250,000
estimated for
1st yr
of program

Input costs not

considered

To evaluate impact
of i.v. to oral
switch program
for ranitidine

OA

Prelpost

None

DCA, pharmacy
preparation costs

Cost avoidance
$4214

Input costs not

considered

To evaluate impact
of H2RA program
on cost and quality
of patient care

OA

Prelpost

None

Patient outcome,
ADRs, drug
interactions. DCA

Decreased cost
but preserved
quality

Input costs not

considered

OA

Control
group

None

DCA

Greater reduction
in M A I D use in
clinic staffed by
RPh, resulted in
cost savings of
$38,776 more
than control
group

Input costs not

considered;
clinical outcomes
not considered;
data collected in
1985- 1986,
report not
published
until 1991

To describe target
DUE program and
determine impact
on drug and labor
costs

OA

Prelpost

None

DCA, NO1

Net annual
savings $18,756

Considered
personnel costs

To evaluate effect
of pharmacistmanaged
anticoagulation
clinical on
therapeutic
outcomes
and costs

CMA

Control
group

Charge for
service

Hemorrhagic
events,
thromboembolic
events, frequency
and charge for
clinic visits, ER
visits, hospital
admissions

Improved clinical
outcomes,
charge avoidance
$4073/person-year

Included clinical
outcomes, used
charges rather
than costs

Target drug programs: NSAIDs

G A A C [~O *]
TO evaluate
(VA)
impact of clinical
RPh activities in
an ambulatory
clinic

~~

- 1995

~ ~ _ _ _
~~

CA, cost analysis; CBA, cost-benefit analysis; CD, cost description: COD, cost/outcome description; CMA, cost-minimization analysis; OA, outcome
analysis; OD. outcome description; CH, community hospital; CP, community pharmacy: ER, emergency room; GAAC, government-affiliated ambulatory
clinic; GH, government hospital; HMOC, health maintenance organization clinic; MC, multicenter; MHF, mental health facility; SNF, skilled nursing
facility: UAAC, university-affiliated ambulatory clinic; UACH, university-affiliated community hospital; UAGH. university-affiliated government
hospital: UH, university hospital; DCA, drug costs avoided; DUE, drug use evaluation; NOI, number of interventions or recommendations; ADRs,
adverse drug reactions; H2RA, histamine2-receptor antagonist; ICU, intensive care unit; LOS. length of hospital stay; NSAIDs, nonsteroidal antiinflammatory drugs; RPh, pharmacist; SDC, serum drug concentration; TDM, therapeutic drug monitoring.

322

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Coleman, R.W.; Rodondi, L.C.; Kaubisch, S.; Granzella,
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Newcomb, H.W.; Hill, E.M.; McCarthy, I.D.; Mostow,
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325

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formulary restriction demonstrates significant cost savings. Hosp. Formul. 1991, 26; 30-32.
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service. Pharmacotherapy 1996, 15 (6), 732-739.

PHARMACY PRACTICE ISSUES

I
More than 17,000 brand and generic names for mcdications are currently approved for prescribing in North
America.' Of those 17,000 chemical entities, a surprising amount have similar dosages. Furthermore, many
names or the medications prescribed today arc spelled or
pronounced in similar ways. This can lead to a substantial
number of errors duc to the misinterpretation and/or
misuse of abbreviations, chemical names, and dosages.lZ1
A study by Lcsar el al. evaluated 696 clinically important
errors in a 63 1 -bed tertiary hospital and round that errors
of nomenclature (incorrect drug name, dosage form or
abbreviation) accounted for 13.4% of all medication errors. The authors further found that one in six errors involved the miscalculation of dosages, incorrect placement
of a decimal, incorrect unit o f measure, or an incorrect
administration rate."' Although poor transcription of a
medication order is an obvious contributing factor for
these types of errors, other factors at the point of prescribing also play a role. Lcsar et al. found that the most
common types of errors made were due to the inappropriate application of drug therapy knowledge (30%) and
the inappropriate use of knowledge regarding patient factors related to drug therapy (29.2c/c).L"
Physician order entry has been recommended as one
possible solution to help to prevent these types of medication errors.['I Initially, the goal of prescribing automation was to decrease the potential for error due to the
misinterpretation of handwritten orders. However, the capabilities o f computers used to aid in medication order
entry now exceed common word-processing duties. Newer systems have allowed clinicians to link patient data to
the prescribing process. Clinicians can use these data to
ensure that the drug dose, timing, and dosage form are
correct, while checking for drug interactions, duplicate
therapy, allcrgies, or disease-state contraindications. A
study by Hates et al. found a greater than 50% reduction
(10.7-4.86 events per 1000 patient days) in nonintercepted serious medication errors after a hospital-implemented
direct physician order entry.'"] Another study found a sig-

'

326

nificmt reduction in error\ due to allcrgies (76%) and

exce\\ivc drug dosages (78 5 % ) after implementation of a
computcmed antiinfective management program 15' Due
to the,e dnd other \tudy re\ult\, the National Patient Safety
Partnership has recommended implementation of direct
order entry strategie5 ' I '

Direct order entry, or electronic prescribing, is not limited

to the inpatient setting. Electronic prescribing encompasses all computer-driven automated processes used to write
a prescription for a patient. Within the past few years,
technological advances have allowed electronic prescribing to be performed in an ambulatory setting. This process
is executed in many ways. Early versions of electronic
prescribing devices consisted of a stand-alone computer
terminal located at fixed points in physicians' office^.'^'^'
These fixed terminals have expanded to use Internet webbased interfaces to access patient lcvcl information from a
health plan, write prescriptions, and send prescriptions to
a pharmacy to be filled.'"
More recent advances in technology made possible by
the personal digital assistant (PDA) have allowed physicians to electronically prescribe at the point of care. PDAs
are handheld computers that typically run using a Windows- or other proprietary-based platforms. These PDAs
use a touch-sensitive screen to maneuver through a menudriven prescribing process that can cxccutc a prescription
in as little as three stylus taps.L91The PDAs or other proprietary devices then upload the prescription via a network
connection or modem to be printed, faxed, or electronically transmitted to a pharmacy.

I
Electronic prescribing devices provide scvcral sources of
information to prescribers at the point of care provided to
Ericjcloywdin of C/iiiiuil I-'hnn?irxy
D01: 10. IOXl/E-ECP 120006404

Copyright 0 2003 by Marccl Dckkcr, Inc. All rights reserved.

Electronic Prescribing

patients. Depending on the level of programming sophistication, and the database links built into the prescribing
device, the clinician can access patient-specific formulary
lists, manufacturer recalled medications, and a host of
clinical references while choosing a therapy. The devices
can also be used to review any managed care disease
treatment protocols at the point of prescribing. It is also
possible for the prescriber to perform drug utilization
review (DUR) analyses to detect any possible drug-drug
interactions, therapeutic duplications, drug-disease contraindications, drug allergies, past adverse reactions, and
inappropriate dosing levels. These therapy edits are either
provided real-time or as possible problems detected upon
transmittal to the electronic prescribing vendor's server.
Finally, electronic prescribing devices allow the user to
provide informational leaflets to patients about their specific therapy.

PRESCRIPTION DESTINATION
Once the prescription has been entered, most electronic
prescribing systems allow prescribers to transmit prescriptions directly to retail or mail order pharmacies electronically or by facsimile. However, some systems use an
intermediary server to process prescriptions before sending them to a pharmacy. The limiting factor for electronic
disposition of prescriptions is the ability to receive the
data. Currently, a large percentage of pharmacies are not
web enabled, and an even larger number of pharmacies do
not operate on an electronic data interface that can speak
to a prescriber's electronic prescribing devise. The solution rapidly being accepted to reconcile these inequities is
a standard data transfer protocol called SCRIPT created
by the National Council for Prescription Drug Programs.
This standard (approved by the American National Standards Institute) has been accepted by most electronic
prescribing device companies, and is rapidly being adopted by large chain drug stores."""]
Who ultimately pays for the electronic prescribing capability is dependent on the electronic prescribing vendor.
Some companies charge prescribers a basic monthly fee
that ranges from $20-$250 per prescriber per month, depending on the level of information provided at the point
of prescribing. This fee typically includes hardware, software, network connectivity devices, upgrades, and a local
Other companies provide hardware and software free of charge to prescribers and charge a second
party for the use of the system. This second party is typically a pharmacy benefit manager or pharmacy, and the
fees range from $. 10-$.20 per prescription."']

327

ADVANTAGES

F ELECTRONIC

Electronic prescribing technology promises to bring many

benefits to the current system of prescribing. The technology promises to bring greater efficiency to the prescribing
process and reduces the likelihood of medication nomenclature errors. The following points highlight the potential
benefits of adopting an automated prescribing system:
Current, unbiased drug information and references can
be provided real-time to clinicians, including educational updates for existing or new chemical entities
and manufacture recalls of medications. This information could include recommended dosing, available
routes of administration, and patient educational materials.", l2]
Patient-specific insurance information can be provided
to prescribers at the point of care, including formulary
lists and disease protocol inf~rmation."~]
Patient-specific medical histories can be provided to
prescribers at the point of care, including last filled
medications, past adverse events, drug allergies, and
medical condition^."^]
Pharmacies and physicians will need to spend less time
contacting each other and insurance companies to
overcome formulary restrictions and problems found
upon drug utilization review, and to clarify illegible
handwriting.[ ,I4]
Physicians and pharmacists can expedite refill requests electronically rather than through person-toperson communication."]
Computers can expedite data exchange between health
care professionals who represent other parts of the patient's health care management team. The sharing of
patient data could lead to less preventable adverse drug
reactions and therapeutic duplications. The provision
of diagnosis data along with prescription information
also allows other heath care providers to check for therapy -diagnosis r n i s m a t c h e ~ . [ ~ " ~ ]
Computers can inform prescribers about lower-cost alternatives and generic availability at the time of prescribing."]

DISADVANTAGES OF ELECTRONIC
PRESCRIBING
Conversely, electronic prescribing has a few potential
disadvantages. Most of these disadvantages stem from the
potential of the technology to be used for other purposes

328

Electronic Prescribing

apart from which it was intended. The following is a

summary of potential misuses of the new technology:
The potential exists for a patients confidentiality to be
violated. Some of the companies offering electronic
prescription solutions download patient information to
a vendor-based server for DUR checks. The security of
this information and what it is used for beyond the
prescribing process creates the potential to impinge
upon the privacy of the patients medical information.
The receipt of a prescription can be subject to several
market barriers. First, the pharmacy must have the
electronic capability to receive the data. Second, the
pharmacy must accept the patients prescription drug
plan and be willing to operate under the financial
constraints imposed by the electronic prescribing
provider. Finally, the potential exists for pharmacy
benefit managers (PBMs) to use electronic prescribing
technology to route prescriptions to preferred pharmacies such as mail order companies.
Physicians will be prompted to adhere to formulary
restrictions and PBM-driven disease protocols more
frequently. As a result, evidence-based prescribing may
become more dependent on the use of appropriate
clinical knowledge by PBMs rather than health care
providers.
This technology can provide a false sense of security
concerning the clinical judgment of the software programming. The programming is limited to the data it
receives and the problems it is designed to detect. The
innate ability of clinicians to question and rationalize
is integral to the process of appropriate prescribing.
However, electronic prescribing technology will make
it easier to overlook the clinicians importance to the
process.
Theoretically, it is possible that electronic prescribing
devices will allow unimpeded access to physicians by
whoever is willing to pay for that access. Physician
detailing may become more prevalent through these
devices and could possibly be confused with unbiased
medication information.

IMPACT ON PRACTICE

OF PHARMACY

The advent of electronic prescribing will decrease pharmacists roles in many areas. In dispensing roles, pharmacists will have less responsibility for order entry, PBM
formulary management, and disease protocol adherence.
Furthermore, a large number of DUR functions will be
taken care of before the patients order is received in

the community or hospital pharmacy. However, the dispensing pharmacy may still function as a redundancy
check on these issues, continuing to act as a patient advocate to manage the appropriateness of patients drug
therapy. The pharmacist will still operate as an integral
check and balance concerning overlooked problems and
missed patient information pertinent to a patients effective drug treatment.
The functions performed by the electronic prescribing
technology will most likely lessen the technical burden of
the pharmacist, while augmenting the need for nontechnical clinical judgment. This augmentation of clinical
judgment should manifest primarily in the review of a
patients situation and pharmacotherapy plan to identify
barriers to the desired patient outcomes.[151Although the
more obvious problems will have a higher likelihood of
being addressed at the point of prescribing, the pharmacist
will still be needed to identify missed pharmaceutical
errors related to dosage route, timing, duration, frequency,
interaction, contraindication, and allergies. The main
emphases of the pharmacist will likely shift to identifying
and treating mismatched medications and indications,
drug overuse and abuse, drug-induced problems, improper
drug use, and potential medication errors.
With a decreased need for pharmacists to identify obvious problems associated with pharmaceutical therapy,
the pharmacist should be free to concentrate on patientcentered therapy issues. Pharmacists can spend more time
with patients identifying barriers that might prevent a
patient reaching an optimal outcome. Pharmacists can
then address these issues with education and proactive
adjustments in the patients therapy. The pharmacist can
concentrate more time on educating patients to better
monitor their therapy to increase the likelihood of maximal therapeutic benefit without troublesome misadventures. Furthermore, the pharmacist could concentrate on
therapeutic outreach programs such as brown bag
clinics, diabetic care clinics, and asthma screening.
In a hospital setting, pharmacists can shift their focus
away from dispensing roles, and take a more proactive
role at the point of care. Lieder reported that the implementation of physician electronic prescribing at Vanderbilt University Medical Center (VUMC) allowed pharmacists to have a greater role in the prescribing process.
Pharmacists reported that clinical evaluations were easier
with electronic records available at the touch of a key.
Pharmacists felt free to pursue other areas of need such as
cost-saving issues (e.g., intravenous to oral conversions of
medications). The technology seemed to promote the presence of pharmacists on the floors to provide drug information to other health care professionals. The VUMC
pharmacy actually maintained the electronic prescribing

329

Electronic Prescribing

$ystem and providcd educationd enhancements directed

at physician5 a9 the need for intervention, in therapeutic
areas aio\e Furthermore, the pharmacy planned to expand
its service, to include an inpatient anticoagulant management program

5.

6.
The future appears very bright for electronic prescribing.
Certainly, the upfront costs for irnplcmenting programs,
and thc refinement of hardwarc and software specifics are
important issues to resolve. However, the benefits of improved care, strcamlined workflow, and more efficient
use of clinicians timc are important enhancements that
have continued to cncourage expansion of these technologies. As wider audiences use these applications, continued
research is needed to assess the use and refinements necessary to optimally apply these important systems.

I.
8.
9.
10.
11.

12.

Institute for Safc Medication Practices. A Call fo Eliminate

Handwritten Pt-e,tcrip/ioa Within 3 Years: Institute for Safe
Medication Practices: 2000; I - 12.
Institute of Medicine. To Err Is Human; Building a Safer
H d t h System;National Academy Press: Washington, DC,
2000.
Lesar, T.S.; Briceland, L.; Stein, D.S. Factors related to
errors in medication prescribing. JAMA, J. Am. Med.
Assoc. 1997. 277 (4). 312 317.
Rates, D.W.; Leape, I,.L.; Cullen, D.J.; Laird, N.; Petersen,
L.A.; Teich, J.M.: Burdick, E.; Hickey, M.; Kleefield, S.;
Shea, B.; Vliet, M.V.; Seger, D. Effect of computerized

13.

14.

15.

16.

physician order entry and a team intervention on prcvention of serious medication errors. JAMA, J. Am. Med.
Assoc. 1998, 280 (15), 1311-1316.
Evans, R.S.; Pestotnik, S.L.; Classen, D.C.; Clernmer, T.P.;
Weaver, L.K.; Orme, J.F.; Lloyd, J.F.; Burke, J.P. A computer-assisted management program for antibiotics and
other antiinfective agents. N. Eng. J. Med. 2001. 338 (4),
232-238.
Rivkin, S. Opportunities and challenges of electronic physician prescribing technology. Med. Interface 1997, 83,
77 -83.
Sardinha, C. Electronic prescribing: The next revolution in
pharmacy? J. Managed Care Pharm. 1998. 4 ( I ) , 35 39.
Pankaskic, M.; Sullivan, J. New players, new services:
E-scripts revisited. J. Am. Pharm. Assoc. 2000, 40 (4),566.
Martin, K.D. Digital prescription pads; bad penmanship?
Essent. Inf. 2000, 2 (1), 3 4.
Ukens, C. Are you ready?Drug Top. 2001. 39; 34 36.
Staniec, D.J.; Goodspeed. D.; Stember, LA.; Schlcsinger,
M.; Schafermeycr, K., ct al. The National Council for
Prescription Drug Programs: Setting standards for electronic transmission of pharmacy data. Drug Benefit Trends
1997, I , 29-35.
Venot, A. Electronic prescribing for the elderly; will it
improve medication usage. Drugs Aging 2001, 15 (2), 77
80.
Armstrong, E.P. Electronic prescribing and monitoring are
needed tu improve drug use. Arch. Int. Med..2000, 160
(18), 2713--2714.
Komshian. S. Electronic prescribing; system helps physicians avoid errors and offer better service. Phys. Comput.
2000, 12-15.
Canaday, B.R.; Yarborough, P.C. Documenting pharmaceutical care: Creating a standard. Ann. Pharmacothcr.
1994, 28, 1292 1296.
Lieder, T.R. Computcrizcd prescriber order entry changes
pharmacists roles. Am. J. Health-Syst. Pharm. 2001, 58
(lo), 846--851.

PHARMACY PRACTICE ISSUES

Hospital Principe de Asturid, Madrid, Spain

TlON
The Encyclopedia of Bioethics defines bioethics as:
The systematic study of the moral-dimensions-including moral vision, decisions, conduct and policies-of the
life sciences and healthcare, employing a variety of
ethical methodologies in an interdisciplinary setting .
Clinical ethics is considered to be a subspecialty of
bioethics and rcfcrs to the daily dccision making of those
who care for the patient.

As emphasized by Dicgo Gracia,* thc professional

relationship between thc health professional and patient
is a social one, although it scems that no one else is
involved. When speaking of third parties, one delimits
within a generic concept of society, a more precise one. In
the professional relationship between the health professional and patient, there are three parties. The relationship is not lineal but rather triangular with three
vertices: the patient, the health prqfessional (physician,
pharmacist, or nurse), and thc society (social structures:
health institutions, health insurance, etc.).
One might think that the health professional and the
patient make, in accordance with the principles of
nonmalcficcnce and autonomy, the decisions they find to
be pertinent. The third parties put them into practice, as if
these were means or instruments to reach an end: the
health professional-patient decision. But thc third parties are structures with their own entity. So much so that
they are guided by a third principlc distinct from that of
the health professionals nonmalcficence principle and that
of the patients autonomy. The principle of the third parties or that of the society is that of justicc. The principle of justice has embodied itself in a political tradition.
Changes in the healthcare model can gcncratc ethical
conflicts. If healthcare is made univcrsal, it covers the
cntirc population. Due to economic crises and scarce
330

rewurccs, it I \ not po\slblc to meet all needs, lust the

basic one\ or those that can be legally claimed. In any
case, the system should guarantee equal acce\s to and fair
di\tribution of limited health resources

ETHICAL THEORIE
~R A MEW O R KFOR
Despite the fact that the new codes of pharmaceutical
ethicsl41 include

the basic principles upon which

bioethics is based (i.e., beneficence, autonomy, and justice), they are not complete enough to serve as a framework for making decisions in concrete situations where
the basic principles come into conflict. In this case, an
ethical foundation and a method are necessary.
The primary foundations are summed up in three
thcorics: the theory of virtue, the deontological theory,
and the consequcntialist theory. (The reader is referred to
other sources for more information.)
Biocthics, basing itself on the moral canon of the
human being and on the ncccssity, as a rational being, to
morally justify oncs own acts, adopts the four ethical
principles: autonomy and ben&cence which pertain to the
private sphere of the individual and nonmaleficence and
justice which pertain to the public sphere.

Decision- Wlakin
Clinical Ethics
For several years, dccision trees have been used in clinical
ethics, although gcncrally in a simplified form without
carriyng out a detailed calculation of probabilities. One of
the first to use this procedure was Baruch Brody, but the
model was more widely accepted due to its simplicity was
that of David C. Thomasma. Albert Jonscn developed a
procedure based on the language of cases and maxims. Sir David Ross, a great English ethicist at the
beginning of the twentieth century, established the principalist method of the analysis of concrete cases. In this
method, he establishes two moments in the moral judgment. First, that of the prima j a c i e obligations and then
Etzrqclopc4ia of Clinic a1 Phnrmucy
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331

Ethical Issues in Clinical Pharmacy

that of actual obligation-that which is a true duty in a

concrete circumstance. In other words, the prima facie
obligations are objectives that can be canceled by other
prima facie obligations of greater urgency. According to
D. Gracia, their present application consists of[61
The a priori moment: The prima facie principles of
autonomy, beneficence, nonmaleficence, and justice.
The a posteriori moment: Real and effective
principles where the prima facie principles that are
in conflict are arranged in order of importance, taking
into account the concrete situation and the foreseen
consequences. The hierarchy can vary according to
each persons perception of a concrete situation. For
this reason, it is best to keep in mind the greatest number of possible viewpoints in an attempt to enrich the
analysis as much as possible before making a decision.
Such is the primary objective of the so-called Institutional Committees of Ethics.
Professor Diego Gracia uses a procedure based on the
analysis of the principles and consequences, like that
suggested by David Ross, and applies it to clinical ethics.
Decision procedure in clinical ethicsL6]

1. Analysis of clinical history by problems (biological, social).

2. Analysis of the clinical biological data and discussion of findings.
3. Identification of possible ethical problems-differentiate, count, and define all the ethical problems found in the clinical history.
4. Selection of the problem that causes a fundamental
conflict of values.
5. Study of the possible courses of action.
6. Selection of the optimum possibility, that which
saves the most values in conflict.
7 . Decision on the course of action to be taken.
8. Analysis of the strong arguments against the decision, as well as the reasons for the decision (ability to defend it publicly).

within the framework of the relationship between health

professional and patient discussed earlier. For teaching purposes and because therapy with medication is
used on almost all patients, this relationship triangle
could be modified. It could be given a new dimension
by converting it into a tetrahedron with the relationship
physician-pharmacist-patient at the base and the society at the upper vertex (Fig. 1). Neither nursing nor the
family is being excluded, as they are included with the
physician and patient, respectively.
Professionals within the clinical relationship should
work within a legal framework that defines the domain of
each and respects the following patient rights:
Confidentiality is the obligation of all health professionals to not reveal to others, without permission of
the patient, information relative to the sick person or
the illness, which goes along with the right to
confidentiality of the patient. But this is a prima facie
obligation, not an absolute one. Thus, when another
person is in danger or the law calls for it, an exception
should be made.
Privacy, a patient right, dictates that no nonauthorized
persons have access to their room, clinical history, or
databases where pertinent information can be found.
Revealing clinical, diagnostic, therapeutic, and prognostic information to the patient, as long as legislation
does not say anything to the contrary, is in the domain
of the treating physician. This fact does not mean that
the pharmacist cannot give the patient information on
the prescribed medication. But, for the benefit of the
patient, it is best that this be done within the
framework agreed upon for the collaboration between
physician and pharmacist.

Third parties -Administration

-Insurance companies
-Judges

/r;

OBLEMS IN THE
PHARMACISTS CLINICAL PRACTICE
Relationship Between Physician,
Pharmacist, and Patient
The pharmacist, as a health professional, can become
immersed in various ethical problems. These are not
unique to the pharmacist; many health professionals must
deal with these same problems.[71 Such conflicts develop

Physician

atient

Fig. 1 Relationship between physician, pharmacist, and

patient.

Ethical Issues in Clinical Pharmacy

332

efinition of the Et

T. L. Beauchamp and J. F. Childress define an ethical

problem as a conflict between two moral obligations
or norms. In general, there are two types of ethical
problems:[s1
Those originating from doubts about the morality of
the act in itself in the face of strongly opposed
arguments.
* Those originating from doubts about the decision
whether to do one thing or another, both being mutually exclusive and implying a moral obligation.

The more specific problems in the pharmacist's clinical practice within this relationship are derivatives
of the therapy with medication, nutrition, hydration, and
placebo treatments.
We can define the ethical problem in pharmacotherapy
as the conflict between moral obligations or norms that
can put in danger the pharmacological treatment that is
best for the patient.

For this reason, as a precursor to the problem, it is

assumed that the pharmacist will maintain professional
competence, and that the pharmacist knows the clinical
history of the patient as well as the circumstances of the
case and preferably of the patient.
A conflict is generated when once the discrepancies
have been discussed with the physician, it is socially
expected that the pharmacist follow the medical order and
dispense the medication prescribed.
This type of conflict can come about in the following
circumstances:

* Omission of a validated and clearly suitable therapy.

* Prescription of nonvalidated therapies, which are considered to be neither suitable nor nonsuitable.
0
Therapies that are clearly nonsuitable.
0
The imposition of therapies on the patient on the part
of the health professionals.
* Patient demand for a therapy not recommended by the
physician.
Practical examples from scientific literature include
obligatory sedation,[" toxic analgesia,"'] the withdrawal
of treatments (antibiotics. nutrition,
and
the use of a placebo.[13]

lassification of Ethical
in ~ h a r ~ a c o t h e r a ~ y
Unavailability of medication
The ethical problems in pharmacotherapy can be classified in the following manner.
Pharmacotherapeutic decisions
These are problems brought about by interprofessional
differences (physician-pharmacist-nurse) in the making
of pharmacotherapeutic decisions:
0

In the evaluation of the benefits and risks of the

necessary pharmacotherapy or that prescribed by a
physician for a patient.
In the inclusion of patient preferences in the pharmacotherapeutic decisions.

The analysis of these problems identifies a conflict of

values or norms. On the one hand, in the first case it is the
moral obligation of the pharmacist to promote the optimum treatment for the patient. In the second case, it is
the obligation of the pharmacist to respect the autonomy
and dignity of the patient.
The most adequate therapeutic decision is the selection
of the therapeutic option that is most valid, taking into
account the patient's circumstances in view of a highly
probable diagnosis and prognosis, which is furthermore
then accepted by the patient.

This is an ethical problem brought about due to lack of

access to or unavailability of medication which is clearly
suitable, with no equally efficient alternatives for a specific patient, orphan drugs, etc.
The present availability of scientific literature to all
professionals in industrialized countries can lead to the
knowledge of the existence of medications that are not
commercially available in our countries. The professional
could feel that it is more appropriate for the patient, but
the administration does not approve its importation.
Another case would be when there is a lack of medicines in a given moment. This rationing would then imply the selection of a population to be treated, and it
would be required that clear and fair criteria be used, such
as the objective criteria of greatest benefit or due to
prognostic factors or even by drawing lots.
The analysis of this problem introduces, on the one
hand, the obligation of the pharmacist to promote the
optimum treatment for the patient, and on the other hand,
the obligation of the administration to establish explicit
criteria for access to or availability of medicines being
researched for severe illnesses or those which are lifethreatening without satisfactory alternative treatments"]
(such as policies on orphan medicines, magistral formulation of nonregistered active ingredients, etc.).

Ethical Issues in Clinical Pharmacy

A conflict can arise between the standard of evidence

considered necessary by the administration, the randomized and controlled clinical study (RCT), and the desire
of the patient to participate in an open trial, compassionated use (CU). This would mean a conflict between
the principle of autonomy (patient) and that of beneficence (administration).
In favor of the open trials CU, it is argued that a
minimum is being required (the RCT), which the patient
does not want, and thus falls into a social paternalism.
Furthermore, it is argued that the investigation of the
clinical practice is possible, carrying out studies of results, without having to do studies with a control-arm
or placebo.
In favor of RCTs, it is argued that since a vulnerable
population is being dealt with, there could be a commercial exploitation upon introducing a medication in a
pathology that does not have therapeutic alternatives,
without having obtained a minimum standard of scientific
evidence. If all of the patients with this pathology are
offered this medication, no comparison can be made
between this alternative and a placebo. Thus, there will be
no certainty of its efficacy, and no other posterior therapy
can be compared with a placebo.

Discrimination
This ethical problem is brought about due to a possible
discrimination either in the use of or the cost for the
patient of the pharmacotherapy.

Negative Discrimination in the Use of the Pharmacotherapy. This refers to the nonutilization of suitable
therapies for elderly patients or women without situations
of comorbidity which justify it."4,'51 The Committee of
Ethical and Judicial Affairs of the American Medical
Association has written reports about age-base rationing,
gender, and black- white disparities in clinical decision
making. [l6l
In reality, negative descrimination does not produce any ethical conflict. It is not ethical in itself, as
it does not respect the principles of nonmaleficence
and justice.
Positive Discrimination in the Use of or in the Cost of
the Pharmacotherapy. An example is the use of epoetin
in patients who do not accept blood transfusions for religious and other reasons. The conflictive principles in
this case could be beneficence and justice. Its use could be
justified if justice is understood as equity, using the
following argument: Blood transfusion is clearly against
the beliefs of this group. These beliefs have been repeatedly infringed upon. According to the principle of

333

equity, more should be given to the most needy, always

applying explicit and transparent criteria.
As far as cost is concerned, positive discrimination
occurs when the administration decides in favor of uublic
financing of complete therapies for certain pathologies.[171

Rationing
These ethical problems are brought about by the denial or
restriction of medicines due to cost.
Rationing according to cost is the systematic and
deliberate denial of some resources, although they could
be very beneficial, because they are considered very expensive. Those cases for which there are less expensive
alternative therapies, which are equally efficient and safe,
are excluded. This would clearly be the most just (principles of rationality and distributive justice) and suitable therapy.
Rationing of a clearly suitable therapy that does not
have an alternative that is equally efficient and safe.
The principles in conflict here would be those of nonmaleficence and justice. The rationing should be
equitable and not infringe upon the "decent minimum." This is ethically acceptable when the rationing criteria are explicit and known to those potentially
affected. This is understood within a framework of
scarce resources in which all of the measures have
been adopted for the rationalization of these.
Rationing of therapies that are thought to be neither
suitable nor nonsuitable (there is no proof for or
against) which are restricted or denied due to their
elevated cost. The conflict in this situation comes
about between the principle of beneficence (if the
physician orders the treatment) or the principle of
autonomy (the patient wants the therapy) and that of
justice. No conflict exists if the patient finances hisher
own treatment, but it does exist if it is financed by the
public health service. Generally, the principle of justice prevails over the other two, and all exceptions
should be justifiable. For decisions for rationing to be
just (distributive justice), they need to be adopted by
the Health Administration.

REFERENCES
Reich, W.T. Encyclopedia of Bioethics (CD-Rom Revised
Edition); MacMillan Library Reference: New York, 1995.
Gracia; D. La relaci6n clhica. Rev. Clin. Esp. 1992, 191
(2), 61-63.
American Pharmaceutical Association. Code of ethics for
pharmacists. Am. J. Health-Syst. Pharm. 1995, 52, 2131.

Ethical Issues in Clinical Pharmacy

334

4.
5.
6.

7.
8.

9.

10.

I I.

FIP Code of ethics 1997. www.fip.nl/publication/

publication1 .htm. (accessed Oct. 2000).
Gracia, D. Fundamentos d~ Hiolica, 1st Ed.; Eudema:
Madrid, 1989.
Beauchamp, T.L.; Childress, J.F. Principles of Biomedical
Ethics, 4th Ed.; Oxford University Press: New York,
1994.
Gracia, D. Proredimientos c>n Etica Clinica, 1st Ed.;
Eudema: Madrid, 1991.
Bucrki, R.A.; Vottero, L.D. Ethical Respon.sahility in
Pharnzary Practice; American Institute of the History of
Pharmacy: Wisconsin. Madison, 1996.
Manolakis, M.L.; Urctsky, S.D.; Veatch, R.M. Scdation of
an unruly patient. Am. J. Hosp. Pharm. 1994,51. 205-209.
van der Heide, A.; van dcr Maas, P.J.; van der Wal, G.;
Kollee, L.A. Using potencially life-shortening drugs in
neonates and infants. Crit. Care Med. 2000, 28 (7), 2595
2599.
Winker, M.A.; Flanagin, A. Caring for patients at the end
of life. JAMA 1999, 282 (20), 1965.

12. Council on Ethical and Judicial Affairs American Medical

Association. Medical futility in end-of-life carc. JAMA
1999, 281, 937-941.
13. Lachaux, B.; Placebo, L.P. Un Medicamento que Busca la
Verdad, I st Ed.; McGraw Hill: Madrid, 1989.
14. Pettersen, K.I. Age-related discrimination in the use of
fibrinolitic therapy in acute myocardial infarction in
Norway. Age and Aging 1995, 24, 198-203.
15. Miller, M.; Byington, R.; Hunninghake, D.; Pitt, B.;
Fuberg, C.D. Sex bias and underutilization of lipidlowering therapy in patients with coronary artery disease
at acadeinical medical centers in the United States and
Canada. For the Prospective Randomized Evaluations of
the Vascular Effects of Norvasc Trial (PREVENT)
Investigators. Arch. Intern. Med. 2000, 160 ( 3 ) , 343 347.
16. www.ama-assn.org/ama/pub/catcgory/25 I3.html (accessed
Oct. 2000).
17. Rothman, D.J. The rising cost of pharmaceuticals: An
ethicists perspective. Am. J. Hosp. Pharm. 1993, 50
(Suppl. 4), 10-12.

PHARMACY PKACTICE ISSUES

ica
Kansas City, Missouri, U.S.A.

IST
Biocthics is a relatively new field of study concerning the
investigation of ethical issues in medicine, health care,
and the life sciences. From the standpoint of bioethics,
clinical pharmacy research presents no novel ethical
questions; however, the type and scope of issues involved
differ from those faced by other practitioners. It is
important for pharmacists to be aware of the ethical
issues, givc thoughtful consideration to then, and be
sensitive to how they may affect their involvement in
research. The current Code of Ethics for the practice of
pharmacy virtually neglects issues encountered by pharmacists as they conduct clinical research."l
Pharmacists arc expanding their responsibilities as
health care practitioners by initiating and participating in
clinical research.121These activities range from custodian
of nonclinical and clinical trial information to principal
investigator cngagcd in original research. For a discipline to survivc as an entity, it must expand its body of
knowledge continuously, rather than relying on other
disciplines to create its knowledge base, including generating data that propose of confirm theories, principles,
or relationships.
Beca~iscof the naturc of ethics, this article presents
more questions than it provides answers; it is difficult to
predefine the right answers to ethical questions. Most
experienced investigators will recognize the circumstances described and will have developed their own
solutions. The article however, should prove useful to new
investigators or trainees, perhaps as a mechanism to
introduce discussion with mentors. It identifies ethical
issues and questions in clinical pharmacy research regarding protection of human subjects, informed consent, conflicts of interest, clinical trial design, investigator independence, and scientific integrity.

Copyright <C I993 by the American College of Clinical Pharmacy

Eizcycloprdia oj Clinical Phi-mat:).
DOI: 10.1081/E-ECP 120006406
Published 2003 by Marcel Dekkcr, Inc. All rights reserved

AL

The Nuremberg Code'"''

and the Declaration of HclsinkiL5' arc accepted international documents guiding the
conduct of human clinical research (Appendices 1 and
2). The Nuremberg Code, established in 1948 after the
war crimes trials of 1946, was the first internationally
recognized code for human research. During the early
19SOs, ethics committees lor clinical research appeared
in the United States. Until then, physician investigators
and research institutes autonomously determined when
investigations became dangerous and to what extent research subjects should be informed. Later the Department of Health, Education, and Welfare [the present
Department of Health and Human Services (DHHS)], in
response to reported abuses of the rights of individuals
participating in certain federally supported research endeavors, mandated that all protocols be screened by institutional committees responsible for the protection of
human subjects. The fedcral government committed itself
when Congress established the National Commission for
the Protection of Human Subjects of Biomedical and
Behavioral Research in 1974. The commission issued the
Belmont report in 1 978;'",7' with that, institutional review
boards (IRBs) were born and principles of protecting the
rights of human subjects participating in research began
to evolve.
The Belmont report describes the basic ethical principles that underlie research involving human subjects:
respect for persons, beneficence, and justice. The report
discusses application of informed consent, assessment of
risks and benefits, and selection of subjects. Its regulations require that IRBs have not fewer than five members
who have the capability to judge research proposals in
terms of community attitudes. Therefore, IRBs must include people whose primary concerns lie in the areas of
legal, professional, and community acceptance rather than
in the overall scientific design.
During the early 198Os, the DHHS developed and
published rules and regulations for the protection of
335

336

human research subjects participation in federally funded

research known as the Code of Federal Regulations. The
Food and Drug Administration published similar regulations governing human research and investigations that
are intended to support marketing permits for drugs, food
additives, medical devices, biologic products, and electronic devices. These sets of regulations serve as the
cornerstone for the oversight of safe human experimentation and guide all who participate in clinical research,
(e.g., IRBs, investigators, research sponsors, research
subjects). Generally, state agencies adopt the federal
standards, and local research institutions interpret and
apply them to all research activities involving humans.

PROTECTION OF HUMAN SUBJECTS

The IRB is charged, by federal, state, and local institutions with ensuring that principal investigators adequately protect the health and well-being of individuals
whose participation may cause them to be at increased
risk to hazards, defined broadly as physical, psychologic,
sociologic, and legal. Thus, it is impossible to conduct
clinical research in humans that would not affect one or
more of these areas.
If local institutions receive any federal research
money, all human research must be approved by the
IRB. This is not the basis for IRB review but provides the
incentive for local institutions to conduct studies that are
ethical. The committee becomes involved in matters such
as confidentiality, anonymity, and moral issues related to
experimental activities. Approval from an IRB, however,
does not relieve the principal investigator from the basic
responsibility of safeguarding the health and welfare of
participating individuals. This is a moral and professional
responsibility that cannot be delegated.

INFORMED CONSENT
Informed consent comprises two distinct concepts.
Informed means that the researcher provides something
(information, assistance with a decision) to the subject.
Consent means that there is something (permission) that
the researcher requests from the subject. Consent must be
given freely.
The informed consent process answers the moral
question, when is it permissible to include competent
people as research subjects? The answer is, if, and only if,
they have given their free and informed consent. Inherent
in this statement is the idea that investigators should ask
for or request consent, not simply to get or obtain it. The

Ethical Issues Related to Clinical Pharmacy Research (ACCP)

mere existence of a signed form does not guarantee that

the informed consent process worked for the benefit of the
subject, but it can facilitate the process. The rights of the
subject must be protected, and informed consent must be
requested and obtained.
A risk-benefit assessment must be performed before a
proposed investigation is submitted to the IRB. Because
the true risk-to-benefit ratio generally is unknown, clear
evidence for a favorable outcome must exist. Benefits
may be gained by individual participants or by society as
a consequence of the proposed activity.
Potential participants must agree in writing to the
conditions of the study after receiving a complete and
understandable explanation of the conditions of participation, the purpose of the activity, and the possible hazards
involved. They must have the right to ask questions and to
withdraw their consent at any stage of the activity.

Ethical Questions Concerning

Informed Consent
Informed consent assumes that accurate information is
being given, that the subject comprehends the information, and that the subject volunteers to participate. Do
investigators emphasize each aspect appropriately? For
example, how does the investigator ensure that the subject
comprehends? Examples of methods used are having the
subject repeat back in her or his own words the information immediately, and repeat it at some future time
while involved in the research; and using a witness to sign
the consent form.
While preoccupied with the informed consent form,
investigators may neglect using required and appropriate
language. How do pharmacists ensure that eighth-grade
language is used on the consent form, and is it ever
verified? If non-English-speaking people are being requested to participate in research studies, the informed
consent form should also be written and presented in
a language they understand. Computer programs and
English teachers may be used to facilitate this process.
Thus, two informed consent forms would be prepared, one
in English and one in the appropriate non-English
language. Investigators should ensure that these issues
are not neglected.
How much information is necessary for potential
subjects to be informed? Should investigators tell the
subjects how much money they are compensated per
subject recruited? It is probably unnecessary for subjects
to understand how clinical research is funded (e.g.,
overhead fees, fees for certain services), unless this
information would influence any reasonable person to
participate (or not to participate). The pharmacy profes-

Ethical Issues Related to Clinical Pharmacy Research (ACCP)

sion and society as a whole determine what reasonable

people usually do, and this is susceptible to change over
time. Research subjects have a right to know what is
known, including the views of the investigators specifically and the pharmacy and medical professions in
general. At minimum, investigators should give subjects
the information that the average reasonable person would
want to know.
Finally, how informed could a subject be about a new
chemical entity when the aim of the study is to gain
information for the first time in humans? To balance the
apparent lack of information, the investigator is responsible for carefully monitoring the subject during all stages
of the investigation.

Payment to Study Volunteers

The informed consent process raises ethical questions.
The informed consent form may state that volunteers will
be paid for their services, yet when does the payment
become simply an inducement? Payment to volunteers for
participation in drug trials is common and usually can be
subdivided into two types, reimbursement for expenses
incurred incidentally and wage payments. Reimbursement
might cover expenses such as transportation costs, costs
incurred by participation (e.g., extra blood sampling, new
drugs or devices being used), and lost work time. Wage
payments involve remuneration for services provided in
serving as a research subject. These payments could be
based on a number of factors, such as time commitment
required, nature, and number of procedures performed, or
to facilitate recruitment in a timely fashion. Payment
should not constitute an inducement.
When ill persons are offered money over and above
expenses to enter a clinical trial of a new drug therapy,
the possibility of coercion exists. The reasoning is that
if the patient is poor, they might not be able to afford
the therapy without entering the trial. Contrast this
experience with renally impaired volunteers recruited
for a pharmacokinetic study of an antibiotic. Renal
failure is not the target of therapy. The subjects receive
no therapeutic benefit from participating and are paid
as volunteers.
The IRBs should review research funding for appropriateness and possible coercion, specifically as it applies
to subject recruitment. If the amount of payment is so
high as to induce any reasonable person to participate,
regardless of the risk, it is obviously too high. It becomes
difficult, however, to determine when coercion is present
because the majority of cases are not this obvious.
Investigators should be able to justify any payment to

337

research subjects. Several factors should be considered in

justifying payment, such as the intensity of the protocol,
whether it is funded and by whom, and the degree of
benefit to subjects other than monetary.

Influence of Drug Therapy

Little information exists about how a patients drug
therapy influences the informed consent process. For
example, can a patient who has had several doses of
intravenous morphine give consent to participate in an
acute myocardial infarction protocol? Sedated patients
may not understand adequately what they are being told;
therefore, they cannot make up their minds freely. As
another example, how informed can patients be who are
experiencing blurred vision from atropine? Does drug
exposure influence continued participation or future
consent? If there are any doubts, a family member,
guardian, or patient advocate should be involved in the
informed consent process.

Adverse Effects
In the context of a clinical trial, informing the patient of
possible side effects could influence the outcome of the
study. However, subjects have the right to know what
may be expected to occur during participation. They must
be informed of all possible adverse effects consistent with
the information in the package insert (if available) and the
information known from other studies.

ETHICAL QUESTIONS C ~ N C ~ R N I ~ G
MORAL PRINCIPLES
Pharmacists, like physicians, have to be aware of the
sovereignty of the patient. Although the protection of
human subjects is critical, there is little opposition to the
protection of human rights. However, opposition to other
critical issues does exist to various degrees.

Questions of Fairness
When should we encourage repeated volunteering? Could
studying the same pool of patients have a negative impact
on the care of others? In other words, volunteering over
and over again may; 1) deny the benefit of that research to
others; 2) make research subjects bear too great a burden
themselves; and 3) result in data that cannot be general-

338

ized to the rest of the population. Careful examination of

the purposes of each investigation must be made to ensure
that repeated volunteering is beneficial to subjects or to
the experimental purpose. Thus, mere expediency of enrolling subjects does not justify studying the same individuals routinely. In some instances, such as pharmacokinetic studies, repeated use of the same subjects may
be acceptable.
Therapeutic research is intended to benefit those who
are the subjects of that research. What are the proper
criteria for inclusion and exclusion that would ensure that
everyone has a fair chance of benefiting from participating within the scope of the hypothesis being tested? The
principle of justice or fairness dictates that subjects be
selected equitably, in other words, giving everyone an
opportunity, and not concentrating on individuals with or
without certain diseases, those located in close proximity
to the service institution, or those of a particular gender.
For example, patients with liver dysfunction commonly
are excluded from research protocols, but in fact are
frequently the ones who receive the study drugs. Consider
also, investigations using predominantly individuals of
one race or ethnic minority simply because of their
availability. Should we encourage the investigation of
drug disposition in these patients, especially as they relate
to the problem being studied?
Thus, selection of subjects has the potential to be an
ethical dilemma. The Belmont Commissions interpretation of the requirement of
is seen in the
following statement:
The selection of research subjects needs to be scrutinized
in order to determine whether some classes (e.g., welfare
patients. particular racial and ethnic minorities, or persons
confined to institutions) are being systematically selected
simply because of their easy availability, their compromised position, or their manipulability. rather than for
reasons directly related to the problem being studied.
Finally, whenever research supported by public funds
leads to the development of therapeutic devices and
procedures, justice demands both that these not provide
advantages only to those who can afford them and that
such research should not unduly involve persons from
groups unlikely to be among the beneficiaries of subsequent applications of the research.

If there are known populations of people in whom

drug disposition and effect differ, should we neglect
enrolling them in clinical trials? Certainly it is expedient
to develop protocols that control for factors that may be a
source of variability. However, in doing this, investigators must not systematically neglect important segments
of the population.

Ethical Issues Related to Clinical Pharmacy Research (ACCP)

Research involving healthy volunteers rarely benefits

the subjects directly, yet may be harmful to them. Should
pharmacists then encourage the development and use of
new technologies or methods (e.g., noninvasive) to reduce
risks while maintaining the scientific integrity of projects? A simple venipuncture exposes both the subject
and the investigator to a degree of risk above that which
occurs in daily life.[6-91If the study drug possesses a saliva : plasma concentration of approximately 1, are we
justified in obtaining plasma samples? If the study intent
is to screen for substances present, investigators should
use noninvasive methods when possible rather than those
requiring venipuncture.

Conflicts of Interest
Conflicts of interest issues are morally relevant because
they represent temptations to do wrong. Million-dollar
budgets have ways of creating ethical dilemmas for
investigators. A prevalent problem is the influence of
commercial interests on independent drug research. Medicine has emphasized disclosure to minimize this problem, but disclosure does not guarantee elimination of
ethical dilemmas.
The American College of Clinical Pharmacy offers
recommendations to minimize conflicts of interest in the
accompanying position statement Pharmacists and the
pharmaceutical industry: guidelines for ethical interactions. The statement addresses questions such as, when
is it permissible to accept an honorarium from a sponsor
for providing a research talk, contributing to a symposium, or arranging a research-oriented training session?
It also discusses the type of research that is appropriate to
be funded. For example, it is unethical to perform a phase
IV study for the sole purpose of familiarizing practitioners with a drug so that they will prescribe or recommend it frequently in the future. Ultimately, the
pharmacist has the responsibility to maintain objectivity
through the unprejudiced and unbiased performance of
research activities regardless of the potential for personal
financial gain.
Another example of a potential conflict of interest is
the use of finders fees to help to identify research
subjects. A finders fee is a fee paid to individuals,
usually nurses, physicians, and pharmacists, who assist
in locating potential research subjects. It may not be
wrong to offer such a fee, but it is probably wrong for
investigators to demand it. It would be unethical to deny
a patient the opportunity to benefit from a study simply
because the investigator would not receive the money. In
lieu of paying finders fees directly, some institutions

339

Ethical Issues Related to Clinical Pharmacy Research (ACCP)

provide credit to a bookstore account or payment to a

special account whose funds can be used only for
educational purposes.

individual Versus Social interest

When is it permissible to deny some benefits, or put some
subjects at risk, for the sake of research and the benefits it
promises? For example, when is it permissible to perform
cost-containment research, and what type of peer review
and informed consent is necessary?["] This is particularly
relevant for pharmacists because many are involved in
this type of data collection and analysis. It is possible that
some subjects may receive a lower standard of care than
that to which they are accustomed. Thus, experimental
strategies that reduce services may expose subjects to the
possibility of harm without benefit.
Political or public policy agendas may exist that do not
necessarily reflect the best interests of research subjects. If
so, pharmacists must maintain the highest standards of
integrity. This may require them to become more involved
in establishing research priorities at federal, state, and
local levels. We should address under what circumstances
it is appropriate to encourage studies that are risky,
potentially unfundable, or would require extensive time or
commitment (which usually means a long delay before
publishable results are generated). The probability of
funding should not determine the direction of research.
Under what conditions is it permissible to delay the
publication of promising results until more substantial
evidence is available? The reverse question is an ethical
dilemma as well. That is, under what conditions is it
permissible to publish promising results even though,
according to accepted standards, more evidence is needed
to validate the results? The increasing newsworthiness of
medical research has given this issue much attention, and
conflicts directly with the established, albeit time-consuming, publication process: manuscript preparation, peer
review, and revision.
Some have criticized the Ingelfinger rule.L111Over a
decade ago, the editor of the New England Journal of
Medicine, Franz Ingelfinger, ruled that no medical
research would be published if it had been published
previously, whether in the scientific or lay press. (The
rule permits previous publication of abstracts or presentations at meetings.) Most major scientific journals have
similar policies.
Vocal patient groups, the lay press, and the public
want medical news as fast as possible; results of new
research are seen or heard daily in the news. The National Institutes of Health has begun releasing some

research results (e.g.. Clinical Alert) directly to health

care providers and the public before the results are published. They deem the results too urgent for the public's
health to be delayed by the publication process." 'I What
are the ethical issues of such early release of research
results, and who is the appropriate authority to decide
what is urgent? How complete should the prepublication
release of medical research be? What is the track record
of prepublication releases? Is it unethical that some
journals take months to print research results because of
their peer review process? Policies should be developed
that define appropriate mechanisms for early release of
research findings, and their effectiveness and impact
should be evaluated.

CLINICAL TRIAL DESIGN

The design of randomized clinical trials introduces ethical
issues."21 Usually, study designs prevent the treatment
from being modified because of the need to collect sufficient data to allow valid statistical inference. Ethically,
clinicians are required to provide their patients with the
best available treatment; however, the justification for a
randomized clinical trial is simply that the best treatment
is not yet known.
What is the proper role for placebo controls? It has
been suggested that, "apart from needing to be both valid
and valuable,' '[131 they must satisfy two premises: there
exists (or there is the likelihood to exist) a controversy
among expert clinicians concerning the relative therapeutic merits of each treatment, including the placebo;
and the design of the study must warrant confidence that
the results will show which of the regimens is superior
and therefore will influence clinical p r a ~ t i c e . " ~ ]
Placebo controls can be justified if the trial is
conducted in an area that falls within one of four
broad categories:

1. Conditions for which no standard therapy exists

at all.
2. Conditions for which standard therapy has been
shown to be no better than placebo.
3. Conditions for which standard therapy has been
called into question by new evidence, creating
doubt concerning its presumed net therapeutic
advantage.
4. Conditions for which validated optimum treatment
is not made freely available to patients because of
cost constraints or other considerations (e.g.,
physical location of treatment centers).

340

These categories should be used as initial guidelines.

The federal Food and Drug Administration desires that
studies of a new chemical entity be compared with
placebo in small groups of patients during phase
I1 testing.
At what point should a clinical trial be stopped
prematurely because enough evidence has been gathered
to show that some treatment is efficacious? Investigators, with the help of statisticians, should develop guidelines that answer this question before the protocol is
submitted to the IRB (or at least prior to data collection). These guidelines should be communicated to all
persons involved in the research effort directly (investigators and research subjects). A safety committee should
be responsible for monitoring data collected during a
trial and stopping the trial if a predefined boundary is
crossed, whether for early evidence of benefit or unacceptable toxicity.

Investigator independence is another important issue.

Almost all industry-funded research is reviewed by the
sponsor prior to publication, and if the results are not
favorable, pressure not to publish may be considerable.
Some protocols forbid the investigator to publish results
without permission; they cite the availability of confidential commercial information as the reason. The implied
threat is that if the results are published, the investigator
will not receive funding in the future. Pharmacists should
be independent investigators with the right and authority
to publish research findings. The intellectual property is
owned by the investigators and their institution, not the
funding agency.

Integrity is a complex concept with associations to conventional standards of morality and personal beliefs about
truth telling, honesty, and fairness. Unintentional investigator bias is a scientific error. Intentional investigator
bias is a form of fraud. Fraud is the deliberate reporting of
what one believes to be false with the intention of deceiving others."41 Within a research program or institution, mechanisms should exist that check for data
trimming, selective reporting, quality control, and originality. Sloppy research is unethical; examples are inconsistencies in record keeping involving research subject
files, sample preparation and other analytical procedures,

Ethical Issues Related to Clinical Pharmacy Research (ACCP)

raw data files, and statistical analysis files. Plagiarism is

another serious offense that compromises scientific integrity and is not acceptable.
Negative data should be published if they are
scientifically sound, particularly when they fill gaps in
current knowledge. They also may decrease redundancy
in future investigations. Investigators should publish
complete information when possible; fragmenting data
sets is discouraged.

CONCLUSI
The research process introduces many ethical questions
particularly relevant to clinical pharmacy investigators.
Most important, investigators must be aware of their
moral responsibility to safeguard the health and welfare of
individuals who participate in research. The informed
consent process is used to ensure that study subjects
understand the conditions of their participation, the
purpose of the study, and the possible hazards involved;
and to ensure that consent is given freely. Investigators
and IRBs must be certain that payments to study volunteers are not excessive or coercive. Finally, clinical
pharmacist investigators must avoid or minimize potential
conflicts of interest by establishing themselves as
independent investigators performing studies with utmost
scientific integrity.

The subcommittee appreciates the helpful comments and

critical review of the following people: David Brushwood, J.D., Peter Iafrate, Pharm.D., Bruce Russell, Ph.D.,
Craig Svennson, Pharm.D., Ph.D., and Russel Thomas,
Pharm.D.
This document was written by the following subcommittee of the 1991-1992 ACCP Research Affairs Committee: David R. Rutledge, Pharm.D., Chair; Clinton
Stewart, Pharm.D., Vice Chair; and Daniel Wermeling,
Pharm.D. Other members of the committee were Kathryn Blake, Pharm.D.; Jacquelien Danyluk, Pharm.D.;
Jimmi Hatton, Pharm.D.; Dennis Helling, Pharm.D.,
FCCP; K. Dale Hooker, Pharm.D.; David Knoppert,
M S c . Pharm.; Patrick McCollam, Pharm.D.; Christopher
Paap, Pharm.D.; Michael J. Rybak, Pharm.D., FCCP;
Kathleen Stringer, Pharm.D.; and Joseph DiPiro,
Pharm.D., FCCP, Board Liaison. Staff editor: Toni
Sumpter, Pharm.D. Approved by the Board of Regents
on May 21, 1993.

Ethical Issues Related to Clinical Pharmacy Research (ACCP)

341

From Pharmacotherapy 1993, 13(5):523-530, with

permission of the American College of Clinical Pharmacy.

1. The voluntary consent of the human subject is

absolutely essential.
2. The experiment should be such as to yield fruitful
results for the good of society, unprocurable by
other methods or means of study, and not random
and unnecessary in nature.
3. The experiment should be designed and based
on the results of animal experimentation and a
knowledge of the natural history of the disease
or other problem under study that the anticipated results will justify the performance of
the experiment.
4. The experiment should be so conducted as to
avoid all unnecessary physical and mental suffering and injury.
5. No experiment should be conducted where there
is a priori reason to believe that death or disabling injury will occur except, perhaps, in those
experiments where the experimental physicians
also serve as subjects.
6 . The degree of risk to be taken should never
exceed that determined by the humanitarian
importance of the problem to be solved by
the experiment.
7 . Proper preparations should be made and adequate
facilities provided to protect the experimental
subject against even remote possibilities of injury, disability, or death.
8. The experiment should be conducted only by
scientifically qualified persons. The highest
degree of skill and care should be required
through all stages of the experiment of those who
conduct or engage in the experiment.
9. During the course of the experiment the human
subject should be at liberty to bring the experiment to an end if he has reached the physical
or mental state where continuation of the experiment seems to him to be impossible.
10. During the course of the experiment the scientist
in charge must be prepared to terminate the experiment at any stage, if he has probable cause
to believe, in the exercise of the good faith,
superior skill, and careful judgment required
of him that a continuation of the experiment is
likely to result in injury, disability, or death to
the experimental subject.

1. Biomedical research involving human subjects

must conform to generally accepted scientific
principles and should be based on adequately
performed laboratory and animal experimentation and on a thorough knowledge of the scientific literature.
2. The design and performance of each experimental procedure involving human subjects
should be clearly formulated in an experimental
protocol which would be transmitted to a specially appointed independent committee for consideration, comment, and guidance.
3. Biomedical research involving human subjects
should be conducted only by scientifically qualified persons and under the supervision of a clinically competent medical person. The responsibility for the human subject must always rest
with a medically qualified person and never rest
on the subject of the research, even though the
subject has given his or her consent.
4. Biomedical research involving human subjects
cannot be legitimately carried out unless the importance of the objective is in proportion to the
inherent risk to the subject.
5. Every biomedical research project involving
human subjects should be preceded by careful
assessment of predictable risks in comparison
with foreseeable benefits to the subject or to
others. Concern for the interest of the subject
must always prevail over the interest of science
and society.
The
right of the research subject to safeguard his
6.
or her integrity must always be respected. Every
precaution should be taken to respect the privacy
of the subject and to minimize the impact of the
study on the subjects physical and mental integrity and on the personality of the subject.
7 . Doctors should abstain from engaging in research
projects involving human subjects unless they are
satisfied that the hazards involved are believed to
be predictable. Doctors should cease any investigation if the hazards are found to outweigh the
potential benefits.
8. In publication of the results of his or her research, the doctor is obliged to preserve the accuracy of the results. Reports of experimentation

Ethical Issues Related to Clinical Pharmacy Research (ACCP)

342

9.

10.

11.

12.

not in accordance with the principles laid down

in the Declaration should not be accepted for
publication.
In any research on human beings, each potential
subject must be adequately informed of the
aims, methods, anticipated benefits, and potential hazards of the study and the discomfort it
may entail. He or she should be informed that he
or she is at liberty to abstain from participation
in the study and that he or she is free to
withdraw his or her consent to participation at
any time. The doctor should then obtain the
subjects freely given informed consent, preferably in writing.
When obtaining informed consent for the research project the doctor should be particularly
cautious if the subject is in a dependent relationship to him or her or may consent under
duress. In that case the informed consent should
be obtained by a doctor who is not engaged in the
investigation and who is completely independent
of this official relationship.
In case of legal incompetence, informed consent
should be obtained from the legal guardian in
accordance with national legislation. Where physical or mental incapacity makes it impossible to
obtain informed consent, or when the subject is a
minor, permission from the responsible relative
replaces that of the subject in accordance with
national legislation.
The research protocol should always contain
a statement of the ethical considerations involved and should indicate that the principles
enunciated in the present Declaration are complied with.

sured of the best proven diagnostic and therapeutic method.

4. The refusal of the patient to participate in a study
must never interfere with the doctor-patient
relationship.
5. If the doctor considers it essential not to obtain
informed consent, the specific reasons for this
proposal should be stated in the experimental
protocol for transmission to the independent
committee.
6. The doctor can combine medical research with
professional care, the objective being the acquisition of new medical knowledge, only to the
extent that medical research is justified by its
potential diagnostic or therapeutic value for the
patient.

Nontherapeutic Biomedical Research

Involving Human Subjects (Nonclinical
iomedical Research)
1. In the purely scientific application of medical
research carried out on a human being, it is the
duty of the doctor to remain the protector of the
life and health of that person on whom biomedical
research is being carried out.
2. The subjects should be volunteers-either healthy
persons or patients for whom the experimental
design is not related to the patients illness.
3. The investigator or the investigating team should
discontinue the research if in his or her or their
judgment it may, if continued, be harmful to
the individual.
4. In research on man, the interest of science and
society should never take precedence over considerations related to the well-being of the subject.

Medical Research Combined with

Professional Care (Clinical Research)
1. In the treatment of the sick person, the doctor must
be free to use a new diagnostic and therapeutic
measure, if in his or her judgment it offers hope
of saving life, reestablishing health, or alleviating suffering.
2. The potential benefits, hazards, and discomforts
of a new method should be weighed against the
advantages of the best current diagnostic and therapeutic methods.
3. In any medical study, every patient-including
those of a control group, if any-should be as-

REFERENCES
1. American Pharmaceutical Association. Code of Ethics;
Washington, DC, 1981.
2. Cloyd, J.C.; Oeser. D.E. Clinical pharmacists in drug
research and development: A historical perspective. Drug
Intell. Clin. Pharm. 1987, 21, 93-97.
3. Anonymous. Trials of War Criminals Before the Nuremberg Militap Tribunals Under Control Council Law No.
10, Vol. 2 ; US Government Printing Office: Washington,
DC, 1949; 181-182.
4. Anonymous. The Nuremberg Code, Appendix 3. In Ethics

343

Ethical Issues Related to Clinical Pharmacy Research (ACCP)

and Regulation (?f Clinical Research, 2nd Ed.; Levine,

R.J., Ed.; Urban & Schwar~enberg: Baltimore, 1986;
425426.
Anonymous. World Medical Association Declaration of
Helsinki: Recommendations Guiding Medical Doctors in
Biomedical Research Involving Human Subjects, Appendix 4. In Ethics and Regulation of Clinical Research, 2nd
Ed.; Levine, R.J., Ed.; Urban & Schwarzenberg: Baltimore,
1986; 427-429.
Department of Health and Human Services. Code of
FedcJral Regulations, 4.5 C.F.R. 46. Pmtec,tion of Human
Subjects; Washington, DC, 1978.
National Commission for the Protection of Human
Subjects of' Biomedical and Behavioral Research. The
Belinont Report: Ethical Principles and Guidelines f o r the
Protpction of Human Subjects of Research. DHEW
Publication 05-78-0012; US Government Printing Office:
Washington, DC; 1978.
Levine, K.J. Basic Concepts and Definitions. In Ethics
and Regulation of Clinical Research, 2nd Ed.; Levinc,

9.

10.

R.J., Ed.; Urban & Schwarzenberg: Baltimore, 1986;

1-18.
Svensson, C.K. Ethical considerations in the conduct of
clinical pharmacokinetic studies. Clin. Pharmacokinet.
1987, 4,217-222.
Brett, A,; Grodin, M. Ethical aspects of human experimentation in health services research. JAMA 1991, 26.5,
1854 1857.
Fletcher, S.W.; Fletcher, R.H. Early release of rescarch
results. Ann. Intern. Med. 1991, 114, 698-~700.
Hellman, S.; Hellman, D.S. Sounding board: Of mice but
not men. Problems of the randomized clinical trial. N.
Engl. J. Med. 1991, 324, 1585- 1589.
Freddman, B. Placebo-controlled trials and the logic of
clinical purpose. IRB: A Review of Human Subjects Research 1985, 7 (2), 1-4.
Levine, R.J. Ethical Norms and Procedures. In Ethics
and Regulation of Clinical Research, 2nd Ed.; Levine,
R.J., Ed.; Urban & Schwarzenberg: Baltimore, 1986;
19-35.
~

11.
12.

13.

14.

PROFESSI 0 NAL 0R G A N IZAT I 0 NS

Annemieke Floor-Schreudering
Europrnn Sooety of Clinical Pharmacy,
Leidcv, The Netherlands

Yechiel Hekster
University Medical Centre, Nijmegen, The Netherlands

oal
In the 20th century, a conviction developed within the
pharmacy profession that the professional knowledge of
pharmacists was not used to its full potential. Activities to
assure the safe and appropriate use of drugs became a new
target, leading to activities in the direction of more paticnt-rclatcd aspects of drug therapy. This perception was
present at about the same time on both sides of thc
Atlantic. It was logically named Clinical Pharmacy,
mcaning a pharmacy activity directed to and in contact
with the patient. The leaders of this new approach wanted
to reinforce their message by founding profcssional organizations preoccupied with the teaching and practical
development of Clinical Pharmacy. In 1979, the birth of
the Amcrican College of Clinical Pharmacy (ACCP) and
the European Society of Clinical Pharmacy (ESCP) took
place simu~taneous~y.

The European Society of Clinical Pharmacy (ESCP) is an

international society founded by clinical practitioners,
rcscarchers, and educators from various countries in
Europe, which constantly looks for new areas of professional practice. Since the formation of the Socicty,
there has been a gradual and sustained growth of clinical
pharmacy in many European countries.

verall
The overall aim of the Society is to develop and promote
thc rational and appropriate use of nicdicines (medicinal
products and devices) by the individual and by society.

344

The goal of ESCP i \ to encourage the development and

education of clinical pharmacist\ in Europe.
The Society tries to achieve this goal by:
1.

Membership activities:
a
Providing a forum for the communication of
new knowledge and developments in clinical
p harmac y .
Dcvcloping links with national and international organizations of pharmacists, teachers,
and students interested in the development of
clinical pharmacy.
0

2.

External relations:
Promoting the value of clinical pharmacy
services among other health care profcssionals, among scicntific societies that share the
same interest, organizations such as WHO
(World Health Organization) and EMEA (European Agency for the Evaluation of Medicinal Products), and generally within the health
service.
0

3. Educational activity:
Enforcing the formation of activities in the field
of clinical pharmacy and pharmacotherapy
through conventions and specific courses.
0
Promoting the inclusion of clinical pharmacy
teaching at pre- and postgraduate levels.

4.

Training:
* Providing accrediting centers, where clinical
pharmacy activities are carried out and which
are prepared to host visiting pharmacists or
pharmacy students in each European country.

Encylopcdia (fClinical Pharmucy

DOI: IO.lOXl/E-ECP
120006205
Copyright 0 2003 by Marcel Dekker, Inc. All rights reserved.

345

European Society of Clinical Pharmacy

5 . Research:
Promoting multicenter research in all areas of
clinical pharmacy.
9
Promoting the participation of pharmacists in
clinical trials and pharmacoeconomic studies.

6 . Publications:
Producing a number of publications on clinical
pharmacy.
Promoting a more widespread use of existing
clinical pharmacy publications.

CLINICAL P H A R ~
Clinical pharmacy is a health specialty, which describes
the activities and services of the clinical pharmacist to
develop and promote the rational and appropriate use of
medicinal products and devices.
Clinical pharmacy includes all the services performed
by pharmacists practicing in hospitals, community pharmacies, nursing homes, home-based care services, clinics,
and any other setting where medicines are prescribed
and used.[21
Activities of the clinical pharmacist are consulting, selecting drugs, providing drug information, formulating and
preparing medicinal products and devices, conducting
drug use studies/pharmacoepidemiology/outcome researcWpharmacovigilance and vigilance in medical devies, studying pharmacokinetics/therapeutic drug monitoring, conducting clinical trials, being aware of the
pharmacoeconomy, dispensing and administrating medicinal products and devices, and providing pre- and postgraduated teaching and training activities to provide training and education programs for pharmacists and other
health care practitioners.[.31

ACTIVITIES OF ESCP

Education and Research

On the day prior to the Annual Symposium, ESCP organizes a one-day full immersion course, Masterclass in
Search of Excellence, on specific topics of interest.
ESCP and EPSA (European Pharmaceutical Students
Organization) jointly organize a Students Symposium,
which aims to bring the clinical pharmacists and pharmacy students together to learn from each others perspectives and experiences.
Different educational and research programs have been
developed and are planned for the coming years (see
ESCP Calendar of Events mentioned below and at www.
escp.nl).
Several collaborative studies, particularly in the field
of drug utilization review and drug evaluation, among
member countries have been or are still in progress.
ESCP offers awards to individual researchers in clinical pharmacy fields in collaboration with sponsors.
A number of accredited centers have been established
to enable European clinical pharmacists to gain experience in a range of clinical pharmacy specialties.
ESCP has produced a database of clinical pharmacy
courses in Europe. Moreover, a long distance Pharmacotherapy Self-Assessment Program (PSAP) published by
ACCP is available at ESCP.

Publications
The editing and issuing of publications and journals is an
important task undertaken by ESCP and comprises the
publication of the Proceedings of the Annual Symposium
in Pharmacy World and Science (PWS). The Society has
adopted a scientific journal Pharmacy World and Science,
where research papers are published and are retrievable.
ESCP Newsletter is a bimonthly publication, serving as
a link between the Society and their members, with news
about the activities of ESCP and of the members.
In addition, ESCP selects existing clinical pharmacy
publications for promotion among ESCP members.

To obtain the goals and objectives, ESCP organizes different types of activities.

elated Organizations
Conferences an
Every year in autumn, the Societys European Symposium on Clinical Pharmacy is held. ESCP also organizes
Spring Conferences, focused on specific themes to provide professional education. During these conferences,
workshops play an important role.

To promote the value of clinical pharmacy services

among other health care professionals and scientific societies, ESCP has established a relationship with societies
that share the same interests: American College of Clinical Pharmacy (ACCP), American Society for Health
Care Systems (ASHP), European Association of Hospital
Pharmacists (EAHP), European Pharmaceutical Students

European Society of Clinical Pharmacy

346

Association (EPSA), Royal Dutch Association for the

Advancement of Pharmacy (KNMP), and the United
Kingdom Clinical Pharmacy Association (UKCPA).
ESCP has been recognized by the Efficacy Working
Party of the European Agency for the Evaluation of Medicinal Products (EMEA) as contributor in the consulting
process. Within the European Forum of Pharmaceutical
Associations and the World Health Organization Regional
Office for Europe (EuroPharm Forum), ESCP is recognized as an observer organization.

The Society is conducted by a General Committee consisting of 12 members. They represent individual countries or, where appropriate, groups of countries. General
Committee members are elected by the membership. The
General Committee meets twice a year, before the Annual Symposium and Spring Conference. (See Table 1
for more information about the General Committee.)

xecutive Committee

The European Society of Clinical Pharmacy International

Office is located at Theda Mansholtstraat 5b, 2331 JE
Leiden, The Netherlands (Phone: + 31 (0)71 5722430;
Fax: + 3 1 (0)71 572243 1; E-mail: [email protected]; Internet: www.escp.nl).

The General Committee elects the Executive Committee,

which implements the resolutions passed by the General
Committee and by the General Assembly. The Executive
Committee, composed of the President, Past-President,
Vice-president, Treasurer, and Chair of the Research and
Education Committee is responsible for the day-to-day
coordination of ESCP activities.

Table 1 General committee members 2001 -2002

~~

Professor M.Alos AlmiAana

Hospital General Castellon, Avda. Benicassim sln, 12004 Castellon, Spain

Ms. C.M. Clark

Brandlesholme, 9 Salthouse Close, BL8 1HD Bury, United Kingdom

Ms.F. Falcao
Hospital de Sao Francisco Xavier, Sevicos Farmaceuticos, Estrada do Forte do Alto Duque, 1495 Lisbon, Portugal
Dr. J. Grassin
Trousseau Hospital, Pharmacy Logipole, Route de Loches, 37 170 Chambray les Tours. France

Dr. E. Grimm Battig

Sonnhaldenweg 28, 4450 Sissach, Switzerland
Professor Dr. Y.A. Hekster
University Medical Centre, Clinical Pharmacy Department, KF 533; P.O. Box 9101. 6500 HB Nujmegen, The Netherlands

Mr. Y. Huon
University Hospital Sart Tilman, Pharmacy Department B 35, 4000 Liege, Belgium

Ms. H. Kreckel
University Hospital Justus-Liebig, Pharmacy Department, Schubertstrasse 89-99, 35392 Giessen, Germany
Mr. K. Linnet
Reykjavik Hospital, Pharmacy Department, Fossvogi, 108 Reykjavik, Iceland

Ms. H. Stenberg-Nilson
Rikshospitalet, Pharmacy, Relis Sor. Holbergs Terrasse, 0027 Oslo, Norway
Dr. F. Venturini
Pharmacy Interna, Policlinico GB Rossi, Piazzale L.A. Scuro, 10, 37134 Verona, Italy

Dr. J. Vlcek
Charles University, Faculty of Pharmacy, Heyrovskeho 1203, 50005 Hradec Kralove, Czech Republic

European Society of Clinical Pharmacy

347

ers

an
The Research and Education Committee is in charge of
the coordination of educational activities, stimulates and
initiates research project, and takes care of the scientific
level of these activities.

The Special Interest Groups (SIGs) of ESCP are intended

to help ESCP meet the evolving needs of its members and
fulfill a growing need for providing targeted services to
ESCP members with similar interests.
The goal is to provide a focal point to gather ESCP
members with common interests and needs in practice,
research, and education, to create a network for:
e
0

e
B

Professional interaction.
Problem solving and discussion of professional issue\.
Continuing education.
Research.
Publications.

The following SIGs are currently active: Cancer Care,

Drug Information, Education and Training, Geriatrics,
Infectious Diseases, Integrated Primary Care, Nutritional
Support, Pediatrics, Pharmacoeconomicr, Pharmacoepidemiology, and Pharmacokinetics.

The Society has an International Office which coordinates

the total operations of the Society, administers the activities of the Society, and implements new policies and
strategies. The staff of the International Office consists of
a director, who i s a pharmacist, and two secretaries. The
director of the ESCP International Office is Annemieke
Floor-Schreudering.

ESCP ha, about 850 members from 48 countries.

Member\ practice in hospitals. clinics, universities, community pharmacies, governmental settings, drug information centers, pharmaceutical industry, and any other
places where clinical pharmacists are employed. The Society has four different classes of members: ordinary
members are individuals who are actively involved in
pursuing the objectives of the Society; honorary members
are those who have distinguished themselves in a particularly honorable way toward the Society; patrons and
sponsors are individuals or corporate bodies, who have
expressed their willingness to support the Society financially; and .student members are individual students or
educational institutions.
During its Annual Symposium, ESCP holds a General
Assembly for all members and patrons of the Society.

C
October 2002

Florencc.

May 2003

Italy
Portugal

3 I st European Symposium
on Clinical Pharmacy
4th Spring Conference o n

C1inic;tl Pharmacy

1. Zelger, G.L.; Scroccaro, G.; Hekster, Y.A.; Floor-Schreudering, A. Introduction to the proceedings. Pharmaceutical
care, hospital pharmacy, clinical pharmacy-what
is the
difference? Pharm. World Sci. 1999, 2f ( 3 ) , lh, A2-A3.
2. Scroccaro, 6.;A16s AlmiRana, M.; Floor-Schreudering, A,;
Hekster, Y.A.; Huon, Y. The need for clinical pharmacy.
Pharm. World Sci. 2000, 22 (l), 27-29.
3. ESCP website. www.escp.nl.

PHARMACY PRACTICE

ISSUES

Univer.sity of Aberdeen, Aberdeen, U.K.

INT
In 1992, a group led by Gordon Guyatt at McMaster
University in Canada first articulated the tcrm evidence based medicine. Evidence-based medicine (EBM)
was defined more recently as the integration of best
research evidence with clinical expertise and patient
values. Despite its recent recognition, EBM has
probably always been practiced by health professionals,
but what has changed is that the quality of evidence and
the clinical benefit of applying it, are now looked at
critically and systematically.
Historically, personal experience, the advice of a
professional colleague or data presented in an article in
a health journal might have been considered sufficient
evidence on which to base a clinical decision. Nowadays,
the importance of using best evidence to underpin
practice is recognized, thereby increasing the likelihood
that an effect can be predicted with confidence. The
growth in EBM has been accompanied by a greater
understanding of the different levels of evidence.
The demand for healthcare increases rclentlessly,
therefore, it is essential that decision makers operate at
both patient and population levels within an evidencebased framework. Evidence is needed for diagnostic tools,
management options (including drug treatments), the
introduction of healthcare models, and patients values
regarding their health service. Scarce resources should
not be spent on treatments which provide little benefit or
which may even do harm. The relative effectiveness of
treatments needs to be assessed where there is competition for limited resources. Valid and reliable information
on the clinical and cost-effectiveness of different options
is therefore needed.
Another reason for the need for EBM is the accelerating pace with which new procedures and treatments are
introduced, with the result that knowledge gained during
training quickly becomes redundant. It is essential,
therefore, to have up-to-date information about best
clinical practice.

348

This article describes how to find and understand the

evidence, and how to apply it in the healthcare setting.

VI
The first stage in practicing EBM is to define the precise
question to which an evidence-based answer is required.
A carefully focused question will inform the search for
relevant evidence, and should (hopefully) avoid excessive
retrieval of irrelevant publications and other information
sources. For example, a clinician who wishes to know
whether it is best to use oral or topical antifungals for the
treatment of vaginal candidiasis could articulate the
question as What is the relative effectiveness of oral
versus intra-vaginal antifungals for the treatment of uncomplicated vulvovaginal candidiasis?
There is a hierarchy] of trial evidence:
la

Evidence obtained from meta-analysis of randomized controlled trials.

Ib

Evidence obtained from at least one randomized

controI1 ed tri a1.

IIa

Evidence obtained from at least one wcll-designed controlled study without randomization.

IIb

Evidencc obtained from at least one other type of

well-designed quasi-experimental study.

111

Evidence obtained from well-designed nonexperimental descriptive studies, such as comparative

studies, correlation studies, and case studies.

IV

Evidence obtained from cxpert committee reports

or opinions and/or clinical experiences of respected authorities.

The above ranking depend$ not only on the type, but

also the quality of the studies. Therefore, a badly conducted randomized controlled trial could be lesq robust
than a well-conducted controlled clinical trial.

Bncjcloyiedia o j Clinical Pharmacy

DOI: 1 0 . 1 OXl/E-ECP 120006244
Copyright C) 2003 by Marccl Dckker, Inc. All rights rescrved.

Evidence Based Practice

349

Table 1 Quality questions for assessing RCTs

0
0
0

*
0
0

avoidance of bias are discussed elsewhere. It is important

to attempt to minimize the effects of bias when reviewing
evidence. It is also useful to contact experts on the subject
of interest, as they will be able to advise on sources of
relevant data and contact details of researchers conducting
trials in the area. Other useful methods of identifying
potentially relevant information include placing notices
about the literature review in professional journals and on
web site noticeboards and searching conference abstracts
and lists of grant awards.
Once the literature search is complete, the identified
trials need to be retrieved and reviewed critically to
decide whether they satisfy specific standards for
inclusion in the review. A list of some important quality
criteria for randomized controls is shown in Table 1. It is
essential that studies that do not meet the necessary
quality standards be excluded from the final analysis.

Were subjects randomly assigned to treatment?

Was randomization done blindly?
Were all subjects analyzed?
Was analysis according to unit of randomization?
Were researchers blind to group allocation?
Apart from the intervention, were the two groups treated
equally?
Were the groups similar at baseline?

It is important to ensure that all the relevant information is identified and critically appraised. This is easier
said than done! Evidence that is unpublished or that is not
in the public domain is difficult to identify and retrieve.
Pharmaceutical companies might not publish unfavorable
results of drug trials, therefore, the clinician or reviewer is
reliant upon the cooperation of the company to provide all
relevant trial data for its specific drug. Trials reported in
the English languager4]and those with positive outcomes
are more likely to be published. Problems can also arise if
trial results have been accepted by a medical journal that
has a long time lag before publication. It may be months
or years before the results are published. The sources and

UNDERSTANDING THE EVIDENCE

The results of trials can be used for different purposes.
They could be combined and reviewed descriptively, or, if

m
T

Table 2 Relative risk

Outcome

Drug A
Drug B

c-d

Where,
a = the number of subjects receiT ing Drug A mith the outcome

b =the number of subjects receiving Drug A without the outcome

c =the number of subjects receiving Drug B Nith the outcome
d = the number of subjects receiving Drug B Mithout the outcome

If the outcome was cure then the relative risk of cure would be calculated as follows:
The risk of cure with Drug A = a ia

b;

divided by the risk of cure with Drug B

c ic + d

with Drug

c ic + d.
Outcome
Yes

No

Total

Durg A

10

20

30

Durg B

50

55

Relative risk = (a / a + b) + (c / c

+ d) = (10 / 30) + ( 5 / 55) = 3.7

This means that cure is 3.7 times more likely with Drug A than Drug B.

350

Table 3 Number needed to treat

Absolute risk iduction(ARR) = (a/(a + b)) - (c/(c + d))
For the above example, using the hypothetical values in Table 2,
ARR=(10/(10+20)) - (5/(5+50))=0.24
Therefore, the NNT = U0.24 = 4
This means that for every four people treated with Drug A, one
additional cure is likely to occur.

the trials are similar enough, their data can be combined

in the form of a meta-analysis. This technique allows
reporting the results to a greater level of statistical confidence because of the increased numbers of subjects included in the analysis.
An alternative statistic which is sometimes quoted is
the odds ratio (OR).This is the odds of an event occurring
in a patient in one treatment group relative to the odds of
the same event occurring in a patient in an alternative
treatment group.
The results of randomized controlled trials comparing
two drugs can be used to generate a statistic called the
relative risk (RR) (Table 2). This is a ratio of the risk of an
outcome with one treatment and the risk of the same
outcome with the other treatment.
While the relative risk is a standard statistic that can
be used to compare treatments, it can be difficult to understand and to relate to practice. For example, although
the relative risk of 3.7 that was calculated above indicates that Drug A is associated with nearly four times
the risk of cure compared with Drug B, this gives no
indication of the practical implications. For this reason,
effects are often quoted as the Number Needed to
Treat (NNT). The NNT is calculated as the reciprocal
of the absolute risk reduction (ARR).In the example in
Table 3, the NNT refers to the number of patients who
need to receive Drug A before an additional cure is
likely to occur.

APPLYING THE EVIDENC

Having identified the evidence from the available information and interpreted it in the context of the original
question, the next step is to apply it to practice. This is a
complex and challenging task. The evidence may suggest benefits from discontinuing existing treatments or
changing to alternative therapy, e.g., using a beta-blocker
in hypertensive patients following a myocardial infarction.] Alternatively, the evidence may recommend
against adopting a new miracle drug such as the anticholinesterase inhibitors for Alzheimers disease.[61

Evidence Based Practice

Currently, much clinical practice is based on established practice and personal experience. Producing
changes in practice will involve the dissemination of information to individual clinicians and persuading them
that, sometimes against their better judgment, there is a
benefit in adopting a new approach. Evans and HainesL7]
cite 12 initiatives to introduce evidence-based practice,
and they are refreshingly honest in identifying the barriers that are encountered. These included the time
required to support change; the resources needed from
existing budgets; a failure to always demonstrate quantifiable gains in the real world; a failure to give ownership
to all parties; and, probably the most difficult and complex of all, changing professional behavior. This last area
is a research topic in its own right and is discussed later
in this article.
Patient resistance to change, as well as professional
resistance, also needs to be addressed. For example, new
evidence may require changes to be made to a patients
current long-term medication. Patients previously satisfied
with their treatment may be reluctant to try a new drug,
despite evidence of greater benefit. A concordant and
patient-centered approach is being promoted.] The clinician has a responsibility to involve their patients in
treatment decisions and to ensure that they understand and
agree with any changes that are made, as well as address
any concerns that they may have. In the interests of maximizing patient outcomes and cost-effective use of medicines, it is paramount that patients understand and agree
with new or existing treatments. Within this framework,
management decisions may not be in line with current best
evidence, giving rise to a debate about the legal implications and professional ethical issues of this scenario.
It is important to remember that EBM applies to a
range of providers at a variety of levels. Thus, it should be
used to support decision making by all healthcare
providers, not just medical clinicians. It is for this reason
that the term Evidence-Based Practice (EBP) is increasingly used. Pharmacy, nursing, physiotherapy, and all
other professions allied to medicine should, where
possible, be providing evidence-based treatment at an
individual and service level. For example, evidence can
support decisions about whether to treat stroke patients
in a dedicated stroke unit or as part of a general ward.[]

CRITICISMS OF EVIDENCE- BASE^ MEDICINE

There are two levels of criticism applied to evidencebased medicine. The first relates to the widespread
dependence on the randomized controlled trial, and the
second relates to the patient-population dichotomy.

Evidence Based Practice

Concern has been expressed that gold standard

evidence, i.e., the RCT, may not be as robust as it first
appears. Critics of this study design argue that the
patient populations are highly selected. Randomized
controlled trials often exclude patients above a certain
age or those who are taking other concomitant medications or who have significant comorbidities. Additionally, participants in RCTs often have intensive support
from medical, nursing, and research staff, contrary to the
normal situation. The reasons for these exclusions and
enhanced care are self-evident, but they may mean that
the results are not generalizable to the wider patient
population. A comparison of randomized and nonrandomized studies has also identified that subjects excluded
from RCTs tend to have worse prognosis than those who
are included.] Furthermore, subjects entered into RCTs
for evaluation of treatment for existing conditions may
be less affluent, less educated, and less healthy then
those who are not. The opposite is true for trials of preventive interventions.[ I
Secondly, clinicians have argued that evidence-based
guidelines do not accommodate individual patients and
their specific circumstances or needs. It may be necessary
to remind clinicians that guidelines are not tramlinesthey apply to a specific population, and their recommendations should be tailored to the needs of their individual
patients. This is discussed later in this article.

PATIENT LEVELS
With increasing healthcare costs, particularly in the field
of drug treatments, decisions regarding the uptake of new
drugs may be made at organizational rather than individual clinician or patient level. In the United Kingdom,
this is particularly true in areas where NHS budgets constrain both the choice of treatment and patient selection.
EBM can be used to inform these policy decisions, as it
can assess both the cost-effectiveness and clinical effectiveness of treatments. The final decision can take into
account the wider ramifications of alternative treatments,
such as the possible need for residential or surgical care or
the impact on lay carers. A decision may be made at a
population level that a new drug should not be introduced
because of the adverse overall health economic balance,
whereas at an individual level, it could be worth trying.
An example of this patient versus the population dilemma is illustrated by the use of the expensive interferon-beta-lb to treat secondary progressive multiple

351

sclerosis (MS). The evidence tells us that treatment with

interferon-beta-1b will delay time to wheelchair dependence and prevent relapses in some subjects. However, the
NNT is 18 and at a population level, the economics mitigate against making this a recommended treatment. ]
Conversely, despite their cost, there has been considerable
use of statins as lipid-lowering agents to reduce cholesterol levels in targeted patients. This is because the
evidence shows long-term reduction in further coronary
events, and the exact health gain can be calculated and is
deemed w o r t h ~ h i l e . ~This

intervention is both clinically and cost effective.

Ultimately, it is the clinician who has to weigh the
costs and benefits for each individual patient, taking into
account the evidence but also considering patient factors.
This has been summarized as conscientious, explicit and
judicious use of current best evidence in making decisions
about the care of individual patients.41

WHAT TO DO WHEN THERE IS NO

EVIDENCE OR EVIDENCE IS INCOMPLETE
The EBM movement is a relatively recent endeavor.
With such a wide range of treatments available and
numerous conditions, it is inevitable that there will not
always be evidence to inform decision making. This may
be due to a lack of collation of the available research
evidence or a lack of research per se. In these instances,
there are several options depending on the immediacy of
the decision.
If a decision needs to made quickly, advice should be
sought from the most experienced practitioner on the
subject. This advice should be interpreted with caution
and considered in light of whatever published literature
exists. This should be judged on the basis of the ranked
levels of evidence included earlier in this article. New
drugs may be tried in the context of local clinical trials.
If this is the case, these trials should be expertly designed
and conducted in collaboration with other colleagues.
This means that while a treatment may not ultimately be
the best, it will have been used in a controlled way such
that it has contributed to generating future evidence.

CLINICAL ~FFECTIVENESSAND
CLINICAL GOVERNANCE
There is a growing emphasis on the accountability of
individual clinicians and organizations that provide

Evidence Based Practice

352

healthcare. EBM contributes to the definition of criteria

used for clinical performance indicators. This forms the
basis of assessing the clinical effectiveness of services.
Increasingly, clinicians and their corporate managers are
held responsible for the delivery of quality care; this is
known as clinical governance. Despite the caveats for
EBM summarized above, the knowledge and understanding it has promoted now underpin the healthcare infrastructures that exist today.

MACISTS ROLE
Pharmacists can contribute to the delivery of evidencebased care.] At a population level, pharmacists clinical
knowledge and analytical strengths can be used to facilitate the production of systematic reviews, the interpretation and analysis of findings, and the development of
guidelines. At a patient level, pharmacists are consulted in
both primary and secondary care, and may be a useful
vehicle for transfer of evidence-based information to the
clinician, being able to give a more objective decision than
the doctor faced with a patient with alternative expectations.61 Pharmacists can influence the choice of prescribed drugs mediated either through the GP to the
patient, or face to face with the patient.17]
In many countries, a wider range of drugs is available
for purchase from pharmacies without the need for a
prescription. This has enabled pharmacists to provide
treatment and advice for a greater range of minor illnesses. Although there have been concerns that pharmacists
and their staff may give inappropriate advice,[l8-*I the
use of evidence-based guidelines to support their treatment of minor illness is currently being explored.[221

RESOURCES FO
EVIDENCEElectronic databases of peer-reviewed healthcare journals
(primary references) include MEDLINE and EMBASE.
The Cochrane Collaboration library contains a database of
systematic reviews as well as a database of RCTs and
controlled clinical trials. Medical librarians will be able
to advise and perhaps provide training on performing
literature searching and retrieval. Hospital-based drug
information centers will likely have access to a range of
electronic databases. The Royal Pharmaceutical Society
of Great Britains information center has a number of
databases that can be searched for information that is of
particular relevance to drug therapy and pharmaceutical
care. It is likely that most national pharmaceutical
organizations have similar resources.
One of the greatest resources for EBM is the World
Wide Web. There are numerous sites that provide
information on EBM. including literature retrieval and
review, EB guidelines, and so on (Table 4).

GETTING EVIDENCE INTO PRACTICE:

DISSEMINATION AND IMPLEMENTATION
The mere dissemination of information (i.e., evidence)
is unlikely to achieve behavioral change.[231In order for
evidence to influence practice, active dissemination and
implementation strategies need to be employed. It is recognized that individual beliefs, attitudes and knowledge
influence professional behavior and that other factors
including organisational, economic and community environments of the practitioner are also important.[241 It
has been suggested that implementation strategies that

Table 4 Suggested EBM-related web sites

Adept Programme
Agency for Healthcare Research and Quality (USA)
Bandolier
Critical Appraisal Skills Programme
National Guideline Clearing (USA)
Netting the Evidence
NHS Centre for Evidence-Based Medicine
National Institute for Clinical Excellence (UK)
Primary Care Clinical Practice Guidelines
Scottish Intercollegiate Guidelines Network (SIGN)
The NHS Centre for Reviews and Dissemination
TRIP Database
UK Cochrane Centre
Virtual library

www.shef.ac.uk/-scharrlirladept
www.ahcpr.gov/
www.jr2.ox.ac.uklbandolier/
www.phru,Org.uk/-casp/index.htm
www.guideline.gov/index.asp
wwwshef.ac.uk/-scharrlirlnettingl
www.minervation.com/cebm/
www,nice,org.uk
www .medicine.ucsf.edu/resources/guidelinesl
www.sign.ac.uk

www.york.ac.uWinst/crd/welcome.htm
www.tripdatabase.com/index.cfm
www .cochrane.org/
www.shef.ac.uk/-scharrlirlcore.htm1

Evidence Based Practice

address barriers to change may be more effective than

those that do not.[241A comprehensive review of implementation strategies is presented in the Effective Health
Cure Bulletin: Getting Evidence Into Practice.[241
The use of guidelines as a method of summarizing
evidence is discussed elsewhere in this encyclopedia.
There has been considerable evaluation of the effectiveness of different guideline implementation strategies as
methods of eliciting behavior change among healthcare
professionals. Most implementation research has targeted physician behavior. However, as greater emphasis is
placed on multidisciplinary healthcare teams, strategies
need to be identified, tested, and adopted, which are effective in promoting evidence-based practice among all
health professional groups.
Mass media is a method commonly used to disseminate information to large audiences. This strategy usually
involves the dissemination of printed materials (e.g.,
guidelines, therapeutic bulletins) to specific health professionals (e.g., physicians, pharmacists). There is little
evidence to support the use of this method, as it is largely
ineffective in influencing behavior change.[251
Educational outreach visits (also known as academic
detailing) have been used by the pharmaceutical industry
for decades to influence the prescribing behavior of
physicians. Although there is little published empirical
evidence of the effect of the pharmaceutical industrys
promotional activities on prescribing patterns, the investment of 57% of their pharmaceutical promotion budget on
pharmaceutical representatives and 11% on promotional
literature, gives some indication of its importance.[261
There is considerable research evidence of the effectiveness of educational outreach as a behavior change strategy
for healthcare professionals.[271 It is no surprise (considering their origin) that educational outreach visits have
been shown to be effective in achieving change in prescribing behavior among physicians.[*]
The use of opinion leaders as an implementation
strategy has been evaluated in a number of studies, the
results of which are inconclusive.[281This method relies
on persuasion (i.e., the persuasive ability of the opinion leader) to influence the behavior of the target
audience. Further evaluation of this strategy is required,
including methods of describing characteristics of opinion leaders and how to identify individuals who satisfy
these criteria.

353

patients receiving the most appropriate treatment. It is

also used to inform policy making about both medical treatments and new services, including models
of healthcare.
While there are still some caveats, some of which have
been highlighted in this article, EBP is the goal to which
all healthcare professionals should aspire.

REFERENC~
1. Evidence Based Medicine Working Group 1992. Evidence based medicine. A new approach to teaching the
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2420-2425.
2. Sackett, D.; Straws, S.; Richardson, W.; Rosenberg, W.;
Haynes, R.B. Evidence Based Medicine: How to Practise
and Teach EBM, 2nd Ed.; Churchill Livingstone: Edinburgh, 2000.
3. US Department of Health and Human Services. Agency f o r
Health Care Policy and Research. Acute Pain Management: Operative or Medical Procedures and Trauma;
AHCPR: Rockville, Maryland, 1993.
4. Egger, M.; Zellweger-Zahner, T.; Schneider, M.: Junker,
C.; Lengeler, C.: Antes, G. Language bias in randomised
controlled trials published in English and German. Lancet
1997, 350, 326-329.
5 . Scottish Intercollegiate Guidelines Network. Secondary
Prevention of Coronary Heart Disease following Myocardial Infarction; 2000, Edinburgh.
6. Coelho Filho, J.M.; Birks, J. Cochrane Collaboration
Physostigmine for Alzheimers Disease. In The Cochrane
LibrarjJ,Issue 3; 2002, Oxford: Update Software.
7. Evans, D.; Haines, A. lmplementirzg Evidence-Based
Changes in Health Care; Radcliffe Medical Press: Oxford,
2000.
8. Working Party: Royal Pharmaceutical Society of Great
Britain. From Compliance to Concordance: Achieving
shared goals in medicine taking. RPSGB and Merck Sharp
& Dohme, 1997.
9. Stroke Unit Trialists Collaboration. Organised Inpatient
(Stroke Unit) Care for Stroke (Cochrane Review). In The
Cochrane Library, Issue 3; 2002, Oxford: Update Software.
10. McKee, M.: Britton, A,; Black, N.; McPherson, K.;
Sanderson, C.; Bain, C. Interpreting the evidence:
Choosing between randomised and non-randomised studies. Br. Med. J. 1999, 319, 312-315.
11. Forbes, R.; Lees, A.; Waugh, N.; Swingler, R. Population
based cost utility study of interferon beta-lb in secondary
progressive multiple sclerosis. Br. Med. J. 1999. 319
(7224), 1529 153 3.
12. Scottish Intercollegiate Guidelines Network. Lipids and
the Primary Prevention of CoroizarI):Heart Disease; SIGN:
Edinburgh, 1999.
~

Evidence-based practice is increasingly recognized as

the best way to maximize the chances of individual

Evidence Based Practice

354

13. Reckless, J. The 4s study and its pharmacoeconomic

implications. PharmacoEconomics 1996, 9 (2), 101 105.
14. Sackett, D.; Rosenberg, W.; Gray, J.; Haynes, R.;
Richardson, W. Evidence based medicine: What it i s and
what it isn't. Br. Med. J. 1996, 3 / 2 , 71 72.
1s. Bond, C. Evidence-Based Phui-macy, 1st Ed.; Pharmaceutical Press: London, 2000.
16. Krska, J.; Cromarty, J.; Arris, F.; Jamieson, D.; Hansford.
D.: Duffus, P.; Downic, G.; Seymour, G. Pharmacist led
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17. Beney, J.; Bero, L.A.; Bond, C. Expanding the Roles of
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Update Software.
18. Goodburn, E.; Mattosinho, S.; Mongi, P.; Waterston, A.
Management of childhood diarrhoea by pharmacists and
parents: Is Britain lagging behind the Third World'! Br.
Med. J. 1991, 302, 440-443.
19. Krska, J.; Greenwood, R.: Howitt, E. Audit of advice
providcd in response to symptoms. Pharm. J. 1994, 252,
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20. Anonymous. Counter advice. Consumers arc still not
receiving the right advice when buying medicines from
pharmacists. Which 1999. 22-25 April.
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pharmacies. Pharm. J. 1986, 237, 807.
Watson, M.C.; Bond, C.; Grimshaw, J.M.; Mollison, J.;
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the promise: Disseminating and implementing practice
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Thompson O'Brien, M.: Oxman, A,; Davis, D.; Haynes,
R.; Freemantle, N.; Harvcy, E. Educational Outreach
Visits: Effects on Professional Practice and Health Care
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Thompson O'Brien. M.A.; Oxman, AD.; Haynes, R.B.;
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PROFESS I0 NA L DEVE LO P M E NT

c
University o f Georgia College o f Pharmacy,
Athens, Georgia, U.S.A.

The term ,fellowship is used to designate training

programs or to indicate status within a profcssion or
professional organization. In pharmacy, the accepted
definition for a fellowship is a directed, highly individualized, postgraduate program designed to prepare
the participant to become an independent researcher.
This definition was adopted by a coalition of seven national pharmacy organizations to distinguish fellowship
from residency training. This definition is contrasted
with that for a resideency which is an organized, directed, postgraduate training program in a defined area
of pharmacy practice. Training fellowships may occur
at any stage of education and are commonly referred to
as predoctorul (usually at the undergraduate levcl) or
postdoctom1 (postgraduate). This article includes discussion of fellowship as a postdoctoral research training program.

DEFINITIONS
A member of a professional organization may be
designated as a fellow to recognize accomplishrncnts, experience, or some other laudable standing in the profession. For example, a person may be a Fellow of the
Arncrican College of Clinical Pharmacy (ACCP) or the
American Society of Health-System Pharmacists (ASHP).
This dcsignation does not indicate completion of a training program nor proficiency in rcscarch.
Fellowships are offered by many institutions, including colleges and univcrsities, government entities such as
the National Institutes of Health and the Centers for
Disease Control and Prevention, pharmaceutical manufacturers, healthcare systems, and professional organizations. Most pharmacy fellowship training programs
are offered by colleges of pharmacy or academic medical centers.

.%7cyck~~~c~dia
of Clirzic.ul Pharmacy
DOI: I0.1081/E-ECI120006357
Copyright 0 2003 by Marccl Dekker, Inc. All rights reserved.

Generally, fellowships are generally highly individualized programs to develop competency in research,
including conceptualizing a research problem, planning and conducting research processes and experiments, analyzing data, and reporting of results. These
programs are conducted under the close supervision
of an experienced research mentor or preceptor. More
so than most residencies, a fellowship is guided by
one person or a small group of individuals. Fellowships are generally 12 or 24 months in duration and
fellows often complete formal courses in selected topics such as research design, statistics, or research
methods before or during a fellowship. Fellows should
possess basic pharmacy practice skills relevant to the
knowledge area of the fellowship. These skills are
acquired through training in a Pharm.D. program, a
residency, or practice experience. For most individuals, a residency should be completed before bcginning
a fellowship.
The goal of fellowship training is to produce an
individual capable of conducting collaborativc research
or functioning as a principal investigator. A fellowshiptrained individual will usually work for a collcge of
pharmacy, academic medical center, pharmaccutical
company, or contract research organization. Researchintensive positions often indicate a hiring preference for
those with fellowship training.

GUIDELINES FOR CLINICAL FELLOWSHI

TRAINING PROGRAMS
In 1987 a document with specific guidelines for clinical
fcllowship training programs in pharmacy was approved
by ACCP and the American Association of Colleges of
Pharmacy.[21The guidelines, which have been updated by
ACCP, relate to the training program overall, preceptor
qualifications, fellow qualifications, and the fellowship
experience, as follows.

355

356

Fellowships in Pharmacy

1. In general, a commitment of 80% of fellowship

training time to research activities over a period of
at least two years.
2. Administrative institutional support for the preceptors research program and the fellowship
training program.
3. Availability of graduate-level course work in the
area of the fellowship.
4. Availability of personnel to teach laboratory-based
and clinical research skills.
5. Ready access to a medical library and computer
facilities.

Preceptor Qualifications
1. A clinical scientist with an established record of
research accomplishments, which may be exemplified by:
a. Fellowship training or equivalent experience.
b. Principal or primary investigator on research
grants.
c. Published research papers in peer-reviewed
pharmacy/medical literature where the preceptor is primary or senior author.

2 . Active collaborative research relationships with

other scientists.
3. Expertise in pharmacotherapeutics in the area
of specialization.

Fellowship Applicant Requirements

1. Pharm.D. or equivalent experience.
2. Residency or equivalent experience.
3. High level of motivation for a research career,

3. Submission of a protocol to the appropriate institutional review committee.

4. Research experiences including study conduct and
data collection related to the field of specialization.
5 . Experience in statistical analysis of data.
6. Preparation and submission of abstracts and
manuscripts for publication in peer-reviewed
journals.
7 . Formal presentation of research at peer-reviewed
scientific meetings.
8. Participation in journal clubs, research workshops,
and seminar series.
9. Instruction in biomedical science ethics.

REVIEW OF FELLOWSHIPS
In an effort to improve fellowship training, ACCP
instituted a program for peer review of research fellowships training programs to assure quality of these programs. This is a voluntary process conducted by an ACCP
committee to determine whether a program meets the
ACCP Guidelines for Research Fellowship Training
Programs as detailed above. In this process, both the
preceptor and the fellowship site are evaluated. A positive
review indicates that the program meets the guidelines. At
present, 15 fellowship programs have been recognized as
meeting the g ~ i d e l i n e s . ~ ~ ]

FELLOWSHIP RESOURCES
An excellent resource for information about pharmacy
fellowships is the ACCP Directory of Residencies and
Fellowships.[31 This source provides information on over
100 individual fellowship programs. Additional information on fellowships can be obtained from the Academy of
Managed Care P h a r m a ~ y ~and
] the American Pharmaceutical Associati~n.[~Currently, fellowships can be
served in the following areas:

Fellowship Experience
The initiation and completion of a research project,
including:

1. Development of at least one scientific hypothesis

and experimental methods to test hypothesis.
2. Preparation and submission of a grant proposal.

* Ambulatory care.
* Cardiology.
* Clinical pharmacology.
* Critical care.
0
Drug development.
0
Drug information.
0
Family medicine.

351

Fellowships in Pharmacy
a
0

e
0

e
e
m
m
e

m
e
0
0

m
0

Geriatrics.
lnlcctious diseases.
Internal rnedicinc.
Managed care pharmacy.
Nephrol ogy .
Neurology .
Oncology.
Outcomes research.
Pediatrics.
Pharmacoeconomics.
Pharmacoepidcmiology.
Pharmacokinetics.
Psychiatry.
Pulmonary.
Rheumatology .
Translational rcscarch.
Transplantation.

Funding for kllowships varies from year to year and

has been available from pharmacy organizations including ACCP, ASHP, American Society of Consultant
Pharmacists, and the American Foundation for Pharmaceutical Education.

I.

Anon. Definitions of residencies and fellowships. Am. J.

Hosp. Pharm. 1987, 44, I143 1144.

Anon. Guidelines for clinical fellowship training programs.
Pharmacotherapy 1988, 8, 299.
3. 2001 Directory or Residencies und Fellowships; American
College of Clinical Pharmacy: Kansas City, 2001.
4. http://www.arncp.org/public/pubs/j~urnal/v~)lS/currentl
reports.htrn1 (last accessed on June 19, 2001).
5. http://www.aphanet.org/ (last accessed June 19, 2001).
2.

P R O F ESS I 0NA L R ESOURC E S

P

ba
First DataBank, Inc., San Bruno, California, U.S.A.

Successful computerization and drug-related decision

support is achieved to a significant degree within the
profession of pharmacy. Pharmacy has been a leader
among healthcare professions in embracing computerization. Drug databases and knowledge bases arc now thc
backbone of pharmaceutical care or pharmaceutical
decision support.

Our mission is to be the best provider of point-of-care

decision support knowledge bases that provide outstanding value to patients and to our customers. We are committed to exceeding our customers expectations so that
they regard us as the best company in our industry. We
will achieve this position through the comprehensiveness and quality of our data, the responsiveness of our
service, and our understanding of their business problems. While continuing to grow, we will provide an open,
supportive, challenging, and team-oriented environment
within which our staff members can achieve job satisfaction, professional and personal growth, and compensation based on company and individual performance.
We will actively work to increase our impact on the
quality of healthcare.
First DataBank is one of the worlds leading suppliers of healthcare knowledge bases, supplying drug
knowledge bases, as well as medical diagnostic and
nutrition software to system vendors. First DataBank
serves hospitals, hospital pharmacies and laboratories,
retail pharmacies, physician clinics and group practices, insurers, managed care organizations, pharmacy
benefits managers, claims processors, employers, utilization review organizations, government, pharmaceutical manufacturers, wholesalers, and all 50 state Medicaid programs.

358

First DataBanks professional staff is committed to

deliver comprehensive and accurate information to physicians, pharmacists, nurses, dietitians, and other healthcare professionals to be uscful in a variety of healthcare
settings. Drug information to be used directly by consumers (i.e., patients and their families) is also another
focus of our drug knowledge bases. Thcsc knowledge
bases are updated continually and are available to accommodate any update schedule, providing the immediate
access that businesses need to perform mission critical
functions and to realize significant time and financial
savings. Enhancements in the delivery of pharmaceutical
care have increased the nced for First DataBank to deliver
clinically significant drug information in a timcly manner. Therefore, updates to products containing clinical knowledge bases ( i t . . drug-drug interactions or patient education materials) are made available on a
weekly basis. Institutional drug buying practices, retail
pharmacy services, and Pharmacy Benefit Manager functions have created the need for daily updates of drug
pricing information.
First DataBank also has many international drug
databases that were developed by a professional staff
consisting of native language speakers who best understand how drugs are used in other countries. As the Internet and global travel make the world a smaller
place, these knowledge bases will become even more
omnipresent and obligatory.
Experience is critical to develop and maintain a comprehensive database of drug information. First DataBank
has been in this business for over 20 years, having spent
virtually all of that time developing, maintaining, and
enhancing the most comprehensive drug, medical, and
nutrition knowledge bases in the world. Our knowledge
bases have evolved along with new technologies in
healthcare and continue to develop as thc Internet and
mobile devices become part of clinical practice. First
DataBank offers customization for every clients file in
terms of record format, formulary selection, media specifications, updates, and user-specific data elements. As

E~zcyclopediuof Clinical Pharmucy

DOl: 10.1081E-ECP 120006382
Copyright 0 2003 by Marcel Dekker, Inc. All rights reserved.

First DataBank, Inc.

359

a result. our customers save valuable programming and

processing time.

Drug Indications, Pregnancy and Lactation Precautions,

GeriatridPediatric Warnings, Minimumhlaximum Dose
Checking, and Duplicate Therapy/Ingredient Checking. A
few specific modules are highlighted.

First DataBank creates and maintains some of the largest

and most comprehensive drug and healthcare knowledge
bases in the world, including NDDF PlusTM,based on the
industry standard National Drug Data FileE. One of the
industrys most trusted and widely used sources of up-todate drug information, NDDF Plus combines descriptive
and pricing data with a selection of advanced clinical
support modules. NDDF Plus delivers information on
every drug approved by the Food and Drug Administration (FDA). Clinical modules are available to support
healthcare professionals in making critical decisions
about dosing and orders, interactions, allergy alerts, disease contraindications, drug identification, and much
more. Plus, several modules offer drug information specifically written for the consumer. NDDF Plus is used in a
wide variety of applications, such as:

Patient Education Monographs were written for consumers. They are both comprehensive and customizable,
covering the most common prescription and OTC medications. The format of these patient education monographs is flexible and is available in English and Spanish.
Other patient education materials are available including
Prioritized Label Warnings that indicate which ancillary
stickers should be placed on a medication being dispensed and Counseling Messages to be used as reminders
for healthcare professionals.

e
e
b

e
0

e
b

b
b

Determining drug indications.

Identifying potential contraindications.
Helping prevent adverse drug events.
Identifying drug-drug and drug-food interactions.
Identifying potential drug interactions with alternative
therapy agents.
Offering printed patient education and counseling
messages.
Prioritizing medication warning labels for patients.
Listing recommended doses for common drugs.
Performing indication-specific dose range checking.
Identifying undesired effects of drugs on lab tests.
Supporting electronic medical records.
Handling prescriber order entry.
Analyzing drug pricing trends.
Facilitating drug formulary management.
Accelerating claims processing and adjudication.

First DataBank offers comprehensive international drug

knowledge bases for several countries outside the United
States, including Canada, Argentina, and Australia. First
DataBank Europe, located in Exeter, England, develops
drug knowledge base products for the United Kingdom.
Examples of clinical functionality in drug knowledge
bases are described below for Patient Education, Drug
Interactions, and Prescriber Order Entry modules. Many
other pharmaceutical decision support modules are also
available and include Drug/Disease Contraindications,

Drug interactions
First DataBanks drug interaction modules are meant to
be able to detect all clinically significant drug-drug
interactions for a given patient in either a prospective or
retrospective manner. Drug-food interaction information
is also available. Interactions are classified by severity,
and documentation levels are also noted in coded fields
for searching and filtering applications. Full text monographs describe the drug-drug interaction in detail and
include reference citations in MEDLINE format. A
consumerized version of the drug-drug interaction
monograph has been created for systems that allow
patients to monitor their medications.

Prescriber Order Entry

Prescriber Order Entry Module (POEMTM)provides a
database of the most common medication orders. These
orders are specific to drug, route of administration, formulation, age, indicatioduse, and weight or body surface area, if applicable. This enables more accurate
and efficient point-of-care computerized order entry applications to prevent errors at the prescribing stage of
drug delivery.

INTEGRATED CO
Success in todays drug information marketplace requires
products that can be developed quickly and economically,
lowering the cost of entry into a given market. Toward
that end, First DataBank offers a number of application

First DataBank, Inc.

360

development toolkits that minimize lead times and make

more efficient use of scarce resources.

rug l n f o r m a t ~ oFrameworkTM
~
The Drug Information FrameworkTM
enables developers to
build healthcare solutions faster, using the time-tested
NDDF Plus knowledge base and critical decision-support
modules. The Framework gives developers a choice of
technologies and access layers, so it can adapt to most
platforms, operating systems, development tools, and relational databases. Application environments can include
the Internet; client/server networks; stand-alone desktops;
and handheld wireless devices.
Drug Information Framework components encapsulate
drug information in intuitive objects, which shortens the
typical programmer learning curve and development cycle. These components simplify system implementation,
resulting in quicker, easier deployment of systems offering
point-of-care, patient-specific drug information, as well as
convenient access to full-text clinical monographs.

HFS FrameworkTM
The AHFS FrameworkTMenables developers to easily
embed drug content into pharmacy and clinical information systems. It can be used to rapidly integrate two
respected drug knowledge bases: the American Hospital
Formulary Service (AHFS) Drug Information i3 monographs, and First DataBanks NDDF Plus. Combined, they
allow healthcare professionals to have seamless access to
comprehensive drug information, within their usual workflow systems.

With Rx InhandTM,developers have a powerful tool for

creating stand-alone handheld applications. This drug
navigation and drug utilization review (DUR) engine
enables developers to easily create systems for use by
physicians to write prescriptions and to screen them on a
handheld device for possible medication errors, thus
potentially minimizing adverse medical events.

RxWebTMprovides instant access to drug information,

navigation capabilities, and clinical-screening functionality over the Internet. Using the latest Web browser
technology, RxWeb enables the developer to offer proven drug screening (via NDDF Plus) with little or no

development time. With RxWeb, software developers

can create Web-based applications that provide information on over 100.000 marketed drugs, as well as alternative therapies.

First DataBank has developed numerous drug reference

products for healthcare applications, in both print and
electronic forms. Most of these products can be deployed
on an individual desktop, a local area network and, in
some cases. over the Internet or intranet,

AHFSfirstTMcombines into one easy-to-use package two

of the most widely used sources of unbiased drug
information-NDDF Plus and the AHFS Drug InformationE monographs from the American Society of HealthSystem Pharmacists$. It links over 100,000 drugs from
NDDF Plus to the AHFS monographs, providing maximum coverage from two respected sources. This sophisticated reference makes it possible, in just seconds, to find
information on drug interactions, contraindications, adverse reactions, and precautions. The AHFSfirst Web
edition brings this capability to users of the Internet or
intranets. AHFS Drug Information monographs are also
available as a data-only product.

Evaluations of Drug InteractionsTM

First DataBanks Evaluations of Drug InteractionsTM
(EDI) provides the most comprehensive printed source
of drug-drug interaction information available. Containing interactions on both prescription and over-the-counter
drugs, this two-volume loose-leaf textbook of drug monographs is the only source endorsed by the American
Pharmaceutical Association.

In addition to drug information products, First DataBank

has developed several interactive software products intended for direct use by healthcare specialists, including
nutritionists and physicians.

utritionist proTM
Nutritionist ProTMsoftware represents the next generation of nutrition-analysis tools from First DataBank.

First IFataRank, Inc.

With the most comprehensive food knowledge base and

set of program features, Nutritionist Pro provides thorough analysis of diets, recipes, and menus. The intuitive user interface design and powerful functionality of Nutritionist Pro can help ease the workload and
boost the productivity of nutrition professionals in virtually any healthcare delivery, food service, or educational setting.

ANTICIPATING FUTURE NEEDS

In healthcare, we are today at a crossroads of yet, another
of many notable technical developments. Personal
computers have become ubiquitous and easier to use for
healthcare professionals and patients. The newly available
mobile or handheld devices have become more practical
for real-time computing. Through the Internet or handeld device, there is ready access to a patients medical
information. With these tools, the art of practicing medicine is truly about to change. An electronic information resource for thc Internet and for handheld devices,
as for other platforms, requires that the data meet specific standards of reliability. First DataBank information is tried and true, a tested, authoritative source of
such information.
First DataBank has anticipated this wave of technological change in medicine and has developed an array
of software and middleware for ease and effectiveness of decision support implementation for these platforms. Time-to-market has become an absolutely critical
factor in the succcss of healtheare IT applications. The
Internet, cost containment, IT undercapitalization, and
a host of other factors impacting the healthcare indus-

361

try have created a demand for the rapid deployment of

new applications.
First DataBank is not only meeting healthcare challenges but is also leading the industry into an era of
greater patient safety and knowledge.

FIRST DATABANK AS A HEARST

CORPORATION SUBSIDIARY
The visionary behind First DataBank is founder and
President, Joseph L. Hirschmann, Pharm.D. Doctor
Hirschmann started the company after a distinguished
academic career at University of California, San Francisco. Another of his accomplishments that lives on today
is the Textbook of Therapeutics: Disease and Drug Munugement, which was previously known as Clinicul Phurmacy and Therupeutics.
First DataBank became part of the Hearst Corporation
in 1980. The Hearst Corporation is one of the worlds
largest diversified communications companies, with interests in newspapers, magazine, book and business publishing, television and radio broadcasting, cable network
programming, and new media activities. First DataBank
remains under established independent leadership, while
benefiting from the support and financial stability offered
by The Hearst Corporation.

LOCATIONS
The First DataBank home office is located in San Bruno,
California, just a few miles from the San Francisco airport. The company also has offices in St. Louis, Missouri;
Exeter, England; and Indianapolis, Indiana.

Medical College of Georgia Hospitals Kr Clinics, Augusta, Georgia, U.S.A.

I
Formulary systems are an essential tool used in a variety
of settings including hospitals, ambulatory clinics, health
plans, pharmacy benefit management companies, and
govcrnrnent agencies. This tool, if used correctly,
promotes rational, clinically appropriatc, safe, and costeffective pharmaceutical carc.
The term formulary has been used to describe a
published list of medications used by an organization,
from which prcscribers can choose therapy for their
patients. Historically, an open formulary implied that
the list was fairly inclusive of any medications the
prescribers wanted. A closed formulary was a finite
list that reflected the clinical judgment of a group of
physicians, pharmacists, and other health care profcssionals meeting regularly to choose the most appropriate
drugs for the list. Most pharmacists have stopped using
open and closcd because few contemporary
formularics arc truly open. A formulary now typically
refers to a book or on-line publication used by the
organimtion that contains the approved drug list and other
prescribing information dccined useful by its editors.
A forinulary systcm goes much beyond a publication
or list of drugs. A coalition of national organizations
representing hcalth care professionals, government and
business leaders has offered this definition:
Drug Formulary System-an ongoing process whereby ii
health care organization, through its physicians, pharmacists, and othcr hcalth care profcssionals, establishes
policies o n the use of drug products and therapies that are
thc most medically appropriate and cost-cffcctive to bcst
serve the health interests of a given population.
This review of formulary systems covers their history,
structure, positive and negative outcomcs, and possible
future directions.

HI

Formularies were t i n t developed in hospitals during the

I9Xh The pharmaceutical market was experiencing
362

unprecedented growth. For example, 17 different companies were marketing 45 different oral penicillin preparations.21 Institutional policies were developed that
allowed pharmacists to dispense a generically equivalent
drug for a brand name product prescribed by physicians.
The pharmaceutical industry and physicians, rcpresented by the National Pharmaceutical Council and the
American Medical Association (AMA) respectively,
successfully worked to get state laws passed forbidding
this substitution by pharmacists. While community
pharmacists complied, hospital pharmacists resisted. In
the late 195Os, the American Society of Hospital
Pharmacists (ASHP) published a set of minimal standards
for pharmacies in hospitals with guidelines for their
interpretation. Among the standards developed was a call
for the implementation of a forinulary system. Interestingly in 1959, the successful launch of anothcr ASHP
publication, the American Hospital Formulary Service, a
reference book reviewing the key characteristics of drugs,
greatly advanced ASHPs financial status and added to
the organizations sphere of influence.
By the 196Os, many hospitals were successful in
developing institutional procedures that gave prior
consent for physician authoriLed pharmacists to select
generic alternatives under what was called a formulary
system. The American Hospital Association (AHA) and
ASHP issued joint statements on the legal basis of a
hospital formulary systcm and the guiding principles for
operating it. A fcw years later, the AMA and APhA
participated with AHA and ASHP to revise the guidelines
to the mutual satisfaction of all parties in a way that
would not alienate the pharmaceutical industry.
In 1965, two significant actions occurred that promoted
formulary systems. Medicare administrators borrowed
freely from ASHPs publications to create standards for
institutional health care resulting in a Medicare bill listing
the use of a formulary system among the eligibility
requirements of Medicare reimbursement. Also, the Joint
Commission required an active pharmacy and therapeutics (P&T) cotnmittcc for hospital accreditation.
Even with these supporting documents and accrcditation standards, adoption of lhrmnlary systems was not as
fast as many anticipated. In the 1970s, two surveys
rcvcalcd surprising results. In the first, of the 172
Encyclopedia o/ Cliniml Pharnzacy
DOT: 10.1081/E-ECP 120006321
Copyright B 2003 by Marcel Dekker, Inc. All rights reserved.

Formulary Systems

Medicare-approved hospitals responding, 3 1 did not have

a formulary system in place even though Medicare
required one.r51The second, looking at academic medical
centers with 500 beds or more, found that the majority of
formularies analyzed were simple drug lists and were not
used to guide prescribing decisions.[61
As the value of formulary systems became apparent,
their acceptance grew, at first just in the hospital setting
but later expanding to ambulatory sites. In 1986, the
Pharmaceutical Manufacturers Association officially accepted the concept of therapeutic interchange for hospital
inpatients, but opposed its use in other settings. The AMA
released a policy on drug formularies and therapeutic
interchange in both inpatient and ambulatory care settings
in 1994.[] This brought the AMAs views on formularies
into close alignment with ASHP. In the most recent
survey of pharmacy practice in acute care settings, more
than 90% of health-systems had P&T committees
responsible for formulary system development and management.@] Pharmacy directors reported using pharmacoeconomic and therapeutic information in their systems
formulary development process. Today, drug formulary
systems are considered an essential tool used routinely by
health plans, pharmacy benefit management companies,
self-insured employers, and government agencies.

The development of a formulary system within an organization rests with a multidisciplinary committee. In the
hospital and health system setting, this is typically called
the P&T committee. Virtually all hospitals and healthsystems have a P&T committee.[81 P&T committees usually meet six to eight times annually. An ASHP Position
Statement on formulary management declares that decisions should be based on clinical, quality of life, and
pharmacoeconomic factors that result in optimal patient
care.[] It advises against decisions solely based on economic factors. The Position Statement also recommends
that decisions must include active and direct involvement
of physicians, pharmacists, and other appropriate health
care providers. This may include dieticians, nurses,
administrators and quality management coordinators.
Formulary system management falls into three general
categories: drug selection for formulary inclusion, formulary maintenance, and medication use evaluation.

Drug Selection
Drug evaluation for inclusion on a formulary should
involve a careful assessment of scientific evidence, in

363

particular, peer-reviewed medical literature, including

randomized clinical trials, pharmacoeconomic studies,
and outcomes research data. If a drug is a new pharmacologic class, unlike any other available drug, the
review will fQCUS on efficacy, safety, and the potential
value to the organizations patient population. For drugs
that are additions to an existing pharmacologic class, the
evaluation takes on a more comparative nature. Reviewers
look for studies that compare the new agent to the agent
currently listed on the formulary. If these are limited or
unavailable, the comparisons are difficult and more
subjective. If two agents appear similar in all clinical
respects, the decision may be a financial one. This process
often results in class review as described later. Reviewers
must remember that new agents coming on the market
have been tested in a limited number of patients. Because
a drugs full adverse effect profile may not be evident
when first released, many committees choose to stay with
the older drug already listed on the formulary until
sufficient information is published.
Two key components of formulary drug selection are
generic substitution and therapeutic interchange. Generic
substitution is the substitution of one drug product for
another when the products contain the same active
ingredients and are chemically identical in strength,
concentration, dosage form, and route of administration.
The formulary will list the drug by its generic name,
strength, and dosage form. The product dispensed will be
the least expensive one. As the price of products change,
the product dispensed may change as well. When this
occurs, the pharmacist should inform the patient if the
physical appearance (e.g., color, tablet size) of their
medication has changed. The patient should be assured
that the new medication is identical to the previous one.
Therapeutic interchange is more complex that generic
substitution. The AMA defines therapeutic interchange as
the authorized exchange of therapeutic alternates in
accordance with previously established and approved
written guidelines or protocols within the formulary
system.71 Therapeutic alternates are drugs with different
chemical structures but which are of the same pharmacologic and/or therapeutic class. They can be expected to
have similar therapeutic effects and adverse reaction
profiles when administered to patients in therapeutically
equivalent doses. The AMA does not support therapeutic
substitution defined as dispensing a therapeutic alternate
for the product prescribed without prior authorization of
the prescriber. Therapeutic interchange in institutional
health systems has been used successfully for years.
Working out an acceptable procedure for therapeutic
interchange by the P&T Committee may be easier in this
setting. Therapeutic interchange in outpatient drug
programs in less structured ambulatory and managed

364

care settings may be more difficult and has been

criticized.['']

Maintaining a formulary is an ongoing process. Policies

and procedures for requests to add and delete drugs from
the formulary must be in place. This includes changing
recommendations for therapeutic interchanges and components of drug use guidelines. As the medical evidence
changes in the published literature, the formulary system
must be able to quickly respond.
Therapeutic class reviews are an important part of
formulary maintenance. The pharmacologic class of drugs
selected for review should be prompted by criteria set by
the P&T Committee."'] These criteria may include the
number of adverse drug reaction reports, new information
in the medical literature, or drug class expenditures. Some
groups may choose to review the class whenever a request
is received to add a new drug from that class to the
formulary. The goal is to always have the best agents
within a class available based on the latest medical
evidence. At the time of the review, new drug use or
treatment guidelines may be considered.
The formulary system should include a mechanism for
patients to receive a drug not listed on the formulary if it
is truly needed. A review of these non-formulary drug
requests may offer insight into areas where the formulary
is not meeting the needs of the health system's patients.
This is true if the review reveals that requests for a
specific agent are justified and frequent. The review may
show that education is needed for the prescriber to steer
them toward a more rational formulary choice.

Medication use evaluation (MUE) is a performance improvement method that is an important part of the
formulary system. MUE focuses on evaluating and improving medication use processes with the goal of optimal patient outcomes.''21 It involves establishing criteria.
guidelines, treatment protocols. and standards of care for
specific drugs and drug classes and the medication use
process (prescribing, preparing and dispensing, administering, and monitoring).

The description of the formulary system leads one to

believe that it would lead to positive outcomes. In the
hospital setting, a significant association has been shown

Formulary Systems

between decreased costs and a well-controlled formulary,

therapeutic interchange, or both."31 Hospitals that used
either strategy spent 10.7% less for drugs than those that
used neither. Hospitals using both spent 13.4% less than
those that used neither. An estimated $100 million in
pharmacy expenditures was saved by the Department of
Veterans Affairs (VA) in two years by implementing a
national f ~ r m u l a r y . " ~A] committee of the Institute of
Medicine found that for inpatient discharges for conditions likely to be affected by the VA formulary's limited
drug list, no increases in hospitalizations were found.['51
The committee did recommend to increase physician
representation on formulary committees and to abandon
the requirement that a drug be marketed in the United
States for a year before it could be admitted to the
formulary. However, convincing research clearly documenting improved patient outcomes is scarce.
Managed care organizations have used formularies to
rein in drug costs but a controversial study concluded that
formularies produced an opposite effect."61 Researchers
found that restrictions on drug availability were linked
to increases in other services shifting costs by increasing the use of either nonrestricted drugs or other health
care services. This study included the use of the restriction method called prior authorization, a method used to
discourage the routine use of an expensive drug by
requiring an approval process before the agent could be
prescribed. In general, the results showed that the more
restrictive the formulary. the higher the drug costs and
the higher the number of prescriptions, outpatient and
emergency room visits, and hospitalizations per patient
per year. The study design and conclusions have been
highly ~riticized."~]
A prior authorization technique involving non-steroidal anti-inflammatory drugs (NSAIDs) in Medicaid
patients was shown to be highly effective."81 NSAIDs not
available generically were place on prior approval status.
This lead to the increased use of generically available
NSAIDs as first line therapy. For a two-year period, the
result was a 53 percent decrease in expenditures (S12.8
million) with no concomitant increase in Medicaid
expenditures for other medical care.

Few ethical questions have been raised in the hospital

setting but in the outpatient setting, there may be concerns. Health plans may try to manage pharmacy costs by
offering incentives to physicians for prescribing lower
cost drugs. This may be depicted as unethical because the
strategy appears to be purely cost driven and possibly

365

lowering the quality of carc. owever; such incentives

may improve quality. For example rewarding physicians
guidelines for treating hypertension
-blocker and a generic thiazide).""'
In presentation at the Joseph A. Oddis Colloquium on
Ethics, it was suggested that the pharmacist play the role
of a pharmacoethicist on P&T

9.
10.

11.
12.
I.

http://www.ashp.org/public/news/breaking/DF-fix.pd~
esscti October 2000).
2. Higby, G.J. Amcrican pharmacy in the twenticth ccntury. Am. 3. Hcalth-Syst. Pharm. 1997. 54 (16), 18051815.
3. Talley, C.R.: Oddis. J.A. In uences and Achievements.
Am. J. Flcalth-Syst. Pharni. 1 97. 54 (16). 1815 1825.
4.
,pita1 Pharmacists: A history. Am. J . Nosp. Pharm.
3. 5 0 (SUPPI. 2). S1-43.
5.
aiids. T.F.: Williams, K.B. How drugs attain formulary

13.

14.

15.

16.
17.
18.

6. Kuckcr, D.T.; Visconti, J.A. Hospital formularics: Organd supplementary components. Am. J.
33 (9). 912-9i7.
7. Amcrican Mcdical Association. AMA policy on drug
forniularics and therapeutic interchange i n inpaticnt and
ilatory patient care settings. Am. J. Hosp. Pharni.
. 51 (14). 1808-1810.
8. Ringold, D.J.; Sanicll, J.P.; Schncider, P.J.; Arcnherg, S.

19.

20.

ASHP national survey of pharmacy practice in acute care

scttings: Prescribing and transcribing--1998.
Am. J.
Health-Syst. Pharrri. 1999. 56 (2). 142- 157.
http://www.ashp.org/bestpracticcs/forinulary/position/
positioi~pdf(accesscd December 2000).
Carroll, N.V. Formularies and therapeutic interchange: The
health care setting rnakcs a difference. Am. J. Health-Syst.
Pharm. 1999, 56 (5). 467 472.
org/bestpracticcs/formulary/gui dc/
esscd December 2000).
http://www.ashp.org/bestpractices/formulary/gui~le/
mcdication.pdf (acccssed December 2000).
FIarlct, T.K.: Hu, T.W. Association bctween forrnulary
strategies and hospital drug expenditures. Am. J. Mosp.
Pharm. 1992, 49 (9). 2207-2210.
Anon. National formulary a plus for VA. Am. J. HealthSyst. Pharm. 2000. 57 (14). 1302.1309,
http://books.nap.edu/catalog/9879.htinl
(accessed Dcccnibcr 2000).
Horn, S.D. Unintended consequences of drug formularics.
Am. J. Health-Syst. Pharm. 1996 5 3 (18), 2204-2206.
Curtiss, F.R. Drug formularies provide path to best care.
Am. J. Health-Syst. Pharm. 1996, 5 3 ( I X ) , 2201-2203.
Snialley. W.E.; Griffin, M.R.: Fought, R.L.:Sullivan, L.;
Ray, W.A. Effect of a prior authorization requirement on
the use of nonsteroidal anti
aid patients. N. Engl. 1 . Me
Smartwood, D.E. Ethics and managed care forinularics.
Am. J. Health-Syst. Pharm.
Jonscn, A. Fortresses and formularies: Ilrugs, ethics, and
managed care. Am. J. Health-Syst. Pharm. 2000, 57 (9),
853-856.

PHARMACY PRACTICE ISSUES

Thc O h i o State University, Columhus, Ohio, U.S.A

olesar
Univer.sity of Wisconsin, Madison, Wisconsin, U.S.A.

I
Extraordinary i n its scope and significance, the human
genome project (HGP) has revealed the complete 3 billion
base pair sequcncc that includes the estimated 35,000
genes of the human genetic blueprint.
One important outgrowth of the HCP is the development of technologies for thc transfer of therapeutic
genes to humans. Undoubtedly, improved biomedical
technology, coupled to a better understanding of the
genetic basis for most human discases, is resulting i n the
rapid identification of new disease targets and the development of innovative gene therapy strategies.l
The numbcr of clinical trials involving human gene
therapy has dramatically increased since the initiation of
the first approved trial in the United States to treat
adenosine deaininasc (ADA) deficiency in 1990.Since
this time, more than 3500 patients have been enrolled in
trials worldwide, with more than 2400 in the United
States.I4 The pharmaceutical industry is actively supporting gene-based therapy by investing billions of dollars, and most major academic medical centers have developed gene therapy programs. The majority of active
trials involve gene therapy for malignancy (6X%), AIDS
( I 8%), and cystic fibrosis (8%1).~
Valuable experience has been gained through rccipients of gene therapy, documenting the technical feasibility of human gene therapy and demonstrating, in most
trials, a relative lack of treatment-related advcrsc effects.
In particular, patients receiving both ex vivo gene therapy,
a procedure whcrc cells are removcd, transfected, and
placed back into thc host, and in vivo gene therapy, in
which the gene vector is placed directly in the patients
body, have tolerated the administration procedures
without acute adverse effects. Despite this, closc attention
has focused on thc relative lack of proven efficacy from
preliminary phase 1 and 11 trials. In gcneral, clinical trials

Encjc~loi~ediii
of Clinird Phcirinac.j
DOI: 10.1081IE-ECP I20006217
Copyright 0 2003 h y Marcel Dekker. Iiic. All rights reserbed

have demonstrated short-term expression o f the gene

product, overall low efficiency of gene expression in the
tissue(s) of interest, and lack of clinical efficacy. For these
reasons, the entire field of g e m therapy has been critically
evaluated at the National Institutes of Health (NIH). In
particular, conclusions from one panel strongly encouraged a redirection back to basic scientific research, with a
particular emphasis on improving vector design.

Gene delivery is the introduction of genes or cells containing gcnes lorcign to the human body for thc purposes
o l prevention, trcatment, diagnosis, or curing disease.
The introduction of exogenous deoxyribonucleic acid
(DNA) into mammalian cells for therapeutic intention can
be accomplished by several techniques that includc
physical, viral, and nonviral methods, each with advantagcs and disadvantages. The majority of clinical experience is derived from viral and nonviral vectors and is
therefore discussed. In all cases, several fundamental attributes are required for a gene therapy vector to be suitable for human use. The vector should be safe to the
recipient, capable 01efficient gene delivery and expression in the targeted tissue, and capable of mass production for human use. Based on these major criteria, the
ideal gene delivery system has yet to be identiried. Of
the more than 425 clinical trials conducted worldwide,
the field remains dominated by retroviruses (37.6%),
adenoviruses (20.2%): and plasmid-based, nonviral vectors such as catioiiic liposomes (1 7.6%).4 Numerous
other vectors and techniques are being used in phase 1
trials, but alone thcy do not comprise greater than 5%

367

Gene Therapy

368

le 1 Comparison of viral transfer techniques

etrovirns
Genome transfer
Virus titer
Purification
Maximum size
In vivo
Integration
Efficiency
Safety issues
Nondividing
Limitation

RNA
lo6- 109
Difficult
8 kB
NO

Yes
High
Mutagenesis
No
Cell division required

Adenovirus
DNA
10"- 1oI2
Yes
8 kB
Yes
No
Very high
Immune reaction
Yes
Transient expression

Liposome
DNA
NAa
Yes
50+ kB
Yes
Low
Moderate
?

Either
NA
Yes
50+ kB
Yes
Low
Low

?
?

Low efficiency

Low efficiency

Key: DNA. deoxyribonucleic acid; RNA. ribonucleic acid.

"NA. not applicable.

of the market share and therefore are not reviewed. Each

of the three major categories of vectors used in clinical
trials has unique attributes and limitations that include,
but are not limited to, DNA-carrying capacity, tropism
for target cells, in vivo transfer efficiency. duration of
gene expression, and potential to induce inflammation
(Table 1).

The fundamental goal of gene therapy is to correct a

singular genetic defect in the cells responsible for causing
disease in the host. To accomplish this, the gene of
interest must be isolated and packaged into a delivery
vector and then introduced to the recipient. The the-

rapeutic gene must enter into the cell intact and travel to
the nucleus where it interacts with the host cell machinery, ultimately being turned into a therapeutic protein
(Fig. 1). A major limitation of most gene therapy is poor
transfer efficiency of the gene to the target cell population. To overcome this obstacle, scientists have turned
to the most efficient, naturally occurring gene vectors
known to human kind-viruses. The primary objective is
to produce virus-based vectors that retain the essential
"gene delivering" features. while also eliminating characteristics associated with infection and host toxicity. Due
to the pathogenic nature of viruses, substantial effort has
also been devoted to the development of synthetic vectors
that chemically mimic the natural gene delivery features
of viruses. The most common viral and nonviral vectors
used in clinical trials share certain attributes but are quite
distinct in many ways. As is discussed, these features
have a substantial impact on therapeutic strategies and, in
certain situations, limit the use of vectors in different
disease states.

etroviral Vectors

Fig. B

Overview of gene therapy.

Retroviral vectors work by reverse transcribing their viral

ribonucleic acid (RNA) genome, which includes the
therapeutic gene insert, into a double-stranded DNA that
becomes stably incorporated in the host cell genome
The virus components associated with rep(Fig. ?.)."I
lication are removed, thereby preventing infectious risk
to the host and providing space for the inserted gene.
The simplest type of retroviral construct is the single
gene vector. In this system, the entire gene cassette of a
functional gene is placed in the retroviral construct with
gene expression controlled by the retrovirus gene promotor. The most widely used retroviral vectors in cli-

Gene Therapy

369

New progeny virus particles each containing reverse transcriptase

Entry

16%

into cell and

_c_

Transcription bq host cell RNA Polymerase

makes many RVA copies

into host chromosome

Fig. 2 Overview of retroviral vector administration.

nical trials are the double gene constructs. They possess

the therapeutic gene, as well as a second marker gene,
such as the neomycin phosphotransferase gene. A significant advantage of the double gene construct is that
cells expressing the gene marker protein can be selected
in culture and then readministered to the patient. Retroviruses integrate the gene insert into the host cell so they
are particularly suited for chronic diseases that require
long-term gene expression to correct the disease phenotype.['] One of the biggest limitations of retroviruses is that
they are relatively unstable following systemic administration.[71 For this reason, most human applications
require removal of the target cells for ex vivo gene
transduction. Retroviral vectors also require that cells
undergo replication during transfection to stably integrate
the gene of interest. Therefore, most clinical protocols
involve induction of cell replication during ex vivo cell

culture to enhance transfection efficiency. However, many

cells exist in a differentiated state; that is, they do not
replicate and may not readily be removed from the host,
thereby preventing the use of retroviruses. An additional
theoretical limitation of retroviral vectors involves insertional mutagenesis. Integration of the genetic material is
random and may occur anywhere in the host genome. It is
therefore theoretically possible that random integration
could disrupt expression of other key proteins.

enoviral V e ~ ~ o r ~
The most extensively used adenoviruses are serotypes 2
(Ad2) and 5 ( A d 3 because both are not associated with
serious infectious disease in humans.['] Similar to
retroviral vectors, elements of adenovirus DNA genome
are removed to prevent replication once inside the

370

Gene Therapy

Packaging Plasmid

@=F5iE!
Retroyiral Vector

Dibision of Packaging \ ector

into Separate gag-pol and en\ for

/Transient Methodl

Tranfection with a \-ector Plasmid

Selection resulting in the

nroducer
line
final ~
~ cell
..
.~
~
~~
~
.~
.. ..
~

Genomes for 2-3 d

45

Recombinant Retrovirus is
secreted into the Media
For harvest

~~~

I
Recombinant Retrovirus is
secreted into the Media for hailis4

Fig. 3 Overview of gene therapy preparation.

mammalian cell. Removal of these elements also

provides space for insertion of a therapeutic gene
(Fig. 3). An additional reason for tailoring the
adenoviral vector genome is to eliminate the expression
of antigenic viral proteins that precipitate a host
inflammatory response. A distinct advantage of adenoviral vectors is that they have broad cell tropism and
can transfect nondividing cells. They can also be
administered systemically via the intravenous, intramuscular, and intranasal routes. From a formulation
standpoint, adenoviral vectors are superior because relatively high titers can be achieved (10" colony-forming
units/milliliter) to ensure convenient dosing in a
minimal volume. Despite these attributes, the adenoviral
vectors possess features that limit their utility. Unlike
retroviral vectors, the gene cassette resides in the
nucleus independent of the host cell genome. Because
stable integration is not achieved, expression of the

gene product is transient. This can be an advantage if

temporary expression will correct the defect; however,
in most strategies, persistent gene expression is required
to correct the underlying disorder. Therefore. maintenance dosing of the vector is required to sustain therapeutic benefit to the patient. In this situation, the other
major limitation of the adenoviral vectors, host toxicity,
becomes a c o n s i d e r a t i ~ n . ' ~ ~The
' ~ ' adaptive host response becomes important because memory is generated
against the vector, thereby amplifying the immune response upon repeat administration and reducing the duration of gene expression. For these reasons, substantial
effort is underway to eliminate adenoviral vector-induced inflammation by selectively removing key antigenic determinants associated with the host response. The
fundamental challenge is to make a safe vector without
removing the ability of the modified virus to efficiently
deliver its genetic payload.

Gene Therapy

Successful transfection depends on both the efficiency of

DNA delivery to the cell (e.g., the fraction of DNA getting
into the nucleus) and the efficiency of DNA expression
(e.g., the amounF of gene that is transcribed). In theory, the
nonviral vector systems are attractive candidates due to
their potential versatility. Despite their use in clinical
trials, the lipid-based systems have several drawbacks.
Many targeting strategies have been developed but few
have worked in vivo. Once the nonviral plasmid expression cassette enters the nucleus, it exists as an episome,
similar to the adenoviral vector; therefore, transient expression is achieved. In general, the lipid-based systems
have a superior safety profile and gene therapy recipients
tolerate high doses without any notable adverse events.
The "Achilles heel" of the nonviral vectors have been
inefficient introduction and expression of DNA into target cells when compared with viral vectors. Another major obstacle with these macromoiecular aggregates that
prevents efficient gene delivery in the host is opsonization.'"] They are recognized as large. hydrophobic macromolecules and are cleared within minutes from the
circulation. Therefore, the fundamental challenge of the
plasmid-based systems is to improve transfection efficiency in vivo. This will likely be achieved by incorporating more features of the most efficient gene delivery
systems, viral vectors, while also maintaining a superior
toxicity profile.

Large-scale production and purification of gene therapy

vectors is critical in advancing the clinical utility of this
new class of medicine. Under ideal circumstances, a
highly purified vector stock should be manufactured with
a relatively stable shelf-life, in a dosage form that is easy
to dispense and ultimately administer to the patient. The
ideal system does not cumently exist for any of the vectors
used in clinical trials."21
In general, vector production is analogous to generating a recombinant protein. The product is a macromolecule that must be derived from cultures of living prokaryotic or eukaryotic cells and purified on a large scale.
The viral components required during vector production
can be defined as cis and trans elements. Cis elements,
for example, transcription initation promotors, must be
carried by the virus itself. Trans elements are removed
from the original viral genome to eliminate infectious

371

risk but are required during production to formulate a

functional viral vector. The trans elements are provided
by a packaging mammalian cell line, thereby providing
the necessary elements to build a functional vector during viral production but without producing an infectious
viral particle. Distinct production, formulation. and patient administration skills are required for each unique
product. From a manufacturing perspective, no standardized test currently exists that can be used to predict
virulence or pathogenicity of each unique vector. Currently, each lot of vector must be individually evaluated
by the manufacturer. All vectors are tested on three basic
principles in preclinical development and large-scale
production before use in clinical trials. Each vector must
demonstrate evidence of safe vector system design, appropriate production of vector stocks under good manufacturing process guidelines, and documentation of
purity under good laboratory practice guidelines. One
review discussed this topic e~tensively."~]
The final product must be free of adventitious
agents that primarily include bacterial or viral pathogens and other biologic contaminates contributed during
cell culture, such as DNA from prokaryotic or eukaryotic host cells and endotoxin. Purity testing for these
factors must be performed throughout the production
procedure and meet defined criteria before administration into humans.
The formulation and packaging of gene delivery
vectors is labor intensive and places a potential burden
on this rapidly advancing field. Vectors currently used in
clinical trials are limited by short shelf-lives. The vector
is then provided to the investigator(s) as a frozen, readyto-use product typically in a glycerol-salt solution. The
vector must be handled as a biohazard, with strict safety
precautions enforced by all personnel prior to, during, and
shortly after administering the vector to the patient. Significant effort is under way to develop convenient dosage
forms for synthetic gene delivery vectors that will sustain
potency on the shelf and allow convenient production,
formulation, and patient administration. Therefore, this
class of vector has a distinct advantage over modified
viruses. Administration to the patient can be done either
in vivo or ex vivo as already described. The major advantage of ex vivo gene therapy is that it ensures delivery
of the gene to the intended cells. The major disadvantages include the amount of time, expertise, and specialized facilities required to accommodate this strategy.
In contrast, in vivo gene therapy involves direct administration of the vector into the patient, which is much
more convenient. However, this creates unique challenges
because the product must be received fresh, handled as a

Gene Therapy

372

biological hazard, and provided to the patient usually

within hours of receiving the product. Currently, no guidelines have been published to address the safe preparation
and handling of gene therapy products. Handling usually
requires that therapies are prepared in biological cabinets
under sterile conditions. Appropriate barriers, including
gloves, gowns, and masks should be worn by those preparing and administering the dose. Gloves and other supplies used in preparation should be autoclaved or decontaminated by ultraviolet light prior to disposal in
biohazardous waste containers. Patient secretions including blood, urine, feces, and respiratory secretions may be
decontaminated with bleach prior to disposal.

The pharmacokinetic and pharmacodynamic parameters

of gene delivery vectors are largely uncharacterized in
humans. However, essential concepts have been described
regarding the many unique aspects inherent to in vivo
distribution of macroparticulate DNA carrier systems. The
distribution of most vectors is predictable and, in most
cases, is limited by physical characteristics of a macromolecule. In general, all gene delivery systems are rapidly
cleared from the systemic circulation, within minutes,
after placement into the bloodstream. This often limits the
capability of the vector to transfect cells in the targeted
tissue. Fortunately, many of the vectors used in clinical
trials can withstand physical manipulation, allowing sitespecific administration in an attempt to enhance expression in defined tissues. Perhaps a greater challenge is to

determine how long a particular gene will be expressed in

a specific tissue once the vector has delivered the therapeutic gene to the targeted cells. Preliminary investigations have addressed this concern, but are limited to
theoretic calculations from in vitro data."41 Ultimately,
this information is essential to develop a gene dosing regimen for a given patient, vector, and disease. Many trials
involve treatment of chronic disorders, including AIDS,
malignancy, and cystic fibrosis in which the gene is being
delivered to differentiated cells with a limited life span.
Therefore, it is presumed that many patients will require
maintenance dosing of a vector to sustain expression of the
therapeutic gene product over time.
Monitoring clinical efficacy of gene therapy has received little attention. For example, in published trials
involving patients with ADA deficiency, the investigators routinely measured serum ADA protein concentrations to document sustained expression of the therapeutic
gene."'] In additional, the patients were extensively monitored for evidence of improved immune function and
decreased number of infections. In the case of cystic fibrosis, the cystic fibrosis transmembrance conductance
regulator (CFTR) protein is not released by transfected
cells and remains associated with the cell membrane in
patients. Knowles et al. had to physically remove nasal
epithelial cells and then use advanced molecular techniques to document protein expression and function.[l6'
Gene therapy strategies undoubtedly create unique challenges for the clinician trying to determine when the
next dose of a gene therapy vector should be administered. Measurement of sustained gene expression, or a
lack thereof, will likely become common laboratory

Table 2 Monogenic diseases: phase I and I1 ongoing gene therapy clinical trials as of February 1, 2001
Gene

Number of
open trials

Chronic granulomatous disease

Cystic fibrosis
Fanconi's anemia
Gaucher's disease
Hemophilia B
Hurler's syndrome
SCIDS

P41 phox
CTFR
FACC
Glucocerebrosidase
Factor IX
IDUA
ADA

2
10
1
1
1
1
5

SCIDS
Purine nucleoside
phosphorylase deficiency

MDR
PNP

Indication

1
1

Countries
U.S.A.
France, U.K., U.S.A.
U.S.A.
U.S.A.
China
U.K.
France, Italy, Japan,
Netherlands, U.K.
Netherlands
U.S.A.

Key: CTFR, cystic fibrosis transmembrane conductance regulator; FACC, factor C; IDUA, a-L-iduronidase: SCIDS, severe combined
immunodeficiency; ADA, adenosine deaminase; MDR, multidrug resistance; PNP, purine nucleoside phosphorylase.

Gene Therapy

373

procedure for gene therapy recipients and require specialized molecular assay techniques.

TH

bT

Monogenic, or single gene disorders, are rare hereditary

disorders usually identified in childhood. They represent
the purest approach to gene therapy, where potentially, the
correction of a single gene defect by gene therapy may
lead to correction of the disease state. The major limitation
of gene therapy for monogenic disorders is that the rarity
of these conditions limits the number of patients able to
participate in clinical trials. The majority of gene therapy
trials for monogenic disorders has focused on severe combined immunodeficiency syndrome (SCIDS)[7s1 and
cystic fibrosis (CF).[193201
In addition, small trials are ongoing in Fanconis anemia, hemophilia, and other diseases
(Table 2 ) .

s
Patients with SCIDS, a rare genetic disorder in which
ADA is absent, have a greatly impaired immune system.
The initial success in gene therapy came in 1989, with the
report of the successful transfection of the normal ADA
gene into T lymphocytes. In the two patients studied, both
had normal immune function restored without adverse
effects. Subsequent studies have demonstrated that both
stem cells and CD34+ umbilical cord cells can be engineered to produce ADA and restore immune function.
Although this disease is extremely rare, it represents the
first successful clinical use of gene therapy.[I7 I

CF should be the ideal candidate for gene therapy because it is a single gene defect and thus presents a clear
target. The main clinical problem is in the lungs, and the
likely target is the surface epithelium. Methods of topical
delivery to the airway surface are already well developed.
All the required components for gene therapy were in
place, and CF gene therapy progressed rapidly from preclinical to clinical studies. The gene, although large, could
easily be inserted into a virus or produced as a plasmid;
cellular studies showed that CFTR gene transfer could
produce functional chloride channels and subsequently
showed that cystic fibrosis cell lines could be corrected.
The next steps were the demonstration of relatively effi-

cient gene transfer to the airway epithelium using reporter

genes in rodents, followed by partial correction of the
disordered airway electrophysiology in CF mice. Clinical
trials soon followed and more than 150 volunteers with
cystic fibrosis participated. The results have been both
encouraging. as gene therapy appears to be possible, and
frustrating. as it just do not work that well. There is good
evidence of low levels of gene transfer and small changes
in ion transport, but progress has been hampered by inefficient gene transfer, immunity to viral vectors, and a
systemic inflammatory reaction provoked by plasmid
DNA, resulting in no clinical benefit to date.93201

ancer
In contrast to monogenic disorders, cancer is generally
caused by multiple genetic defects, providing no clear
single target for gene therapy. However, because cancer is
the second leading cause of death in the United States,
gene therapy is under intensive investigation. Rather
than correcting the multiple genetic defects found in
tumors, cancer investigators have generally investigated
approaches to conferring drug sensitivity, either by
transvecting tumor cells with a gene encoding an enzyme
such as herpesvirus thymidine kinase (HSV-TK)[] that
can metabolize a nontoxic drug to its toxic form (suicide
genes) or with p53 (Table 3).[221
The majority of gene therapy clinical trials are for
cancer, with trials ongoing for almost all types of cancers.
In addition, gene therapy for cancer is closest to the clinic,
with both p53 and HSV-TK gene therapy in phase 111
clinical trials (Tables 4 and 5).

SV-TK
The HSV-TK gene converts nontoxic nucleoside analogs
such as ganciclovir into phosphorylated compounds that
kill dividing cells. Therefore, cells genetically modified
to express the HSV-TK gene can be killed by the administration of ganciclovir.[211
This cytotoxic effect of transduced cells on nontransduced cells is termed the bystander effect.[231Because only
a small number of cells will be transduced with the
cytotoxic gene, when these cells die, they release toxic
products that in turn kill the surrounding (or bystander)
cells. The TK-ganciclovir approach is currently used in
several clinical trials for a variety of malignancies, including g l i o m a ~ . ~ ~
Adenoviral (Ad)-mediated intrapleural HSV-TK-ganciclovir gene therapy has been tested primarily in phase I
and I1 clinical trials in patients with mesothelioma,

Gene Therapy

374

Table 3 Oncology: phase I and I1 ongoing gene therapy clinical trials as of February 1, 2001
~

Number of trials

Gene

Breast
Cervical
CML
Colon cancer
Head and neck
Head and neck
Glioblastoma

c-erb-b2
HPV
HSV-TK
CC49 zeta TcR chimera
INF
IL-12
HSV-TK

Lymphoma
Lymphomas and leukemias
Melanoma

MDR I
Specific idiotype
IL-2

1
3
6

Melanoma
Melanoma
Melanoma
Melanoma
Melanoma
Melanoma
Mesothelioma
Metastatic cancer
NSCLC
NSCLC
NSCLC
O\ arian
01aiian
01arian, piostate. and breast
Ox m a n
Pancreas
Prostate
Prostate
Prostate
Prostate
Prostate
Renal cell
Renal cell
Superficial solid tumors

IL-7, IL-12, Gm-CSF

IL-4
GM-CSF
IL-6
HLA-B7/beta 2 micro
MART1 +gplOO
IL-2
IL2
P53
IL-2
GM-CSF
HLA-A2
P53
BRCAl
Mo\ -gamma
Cytochrome p450
IL-2
PSA
P53
GM-CSF
HSV-TK
IL-2 + HLA B7
HLA B7/Beta 2 micro
IL-2

3
2
1
1
2
2
1
2
1
1
1
1
2
2
1
1
1
3
I
2
1
1
2
1

glioblastomas, or ovarian cancer. The gene was administered intrapleurally in patients with mesothelioma or
oharian cancer and by direct injection during surgery in
those with glioblastomas. In most phase I trials, the doselimiting toxicity was not reached. Side effects have been
minimal and included fever. anemia, transient liver enzyme elevations, and bullous skin eruptions, as well as a
temporary systemic inflammatory respouse. Using RNA
polymerase chain reaction (PC ), in situ hybridization.
immunohistochemistry, and immunoblotting, HSV-TK
gene transfer has been documented in approximately
50% of patients. Clinical activity has been minimal, al-

Country
U.K.
U.K.
U.S.A.
U.S.A.
U.S.A.
U.S.A.
Finland, France, Spain,
Switzerland, U.S.A.
U.K.
U.S.A., U.K.
Germany, France, Italy,
Netherlands, U.K., U.S.A.
Germany
Italy
Netherlands
Poland
U.S.A.
U.S.A.
Australia
France, Switzerland
U.S.A.
U.S.A.
U.S.A.
Singapore
U.S.A., U.K.
U.S.A.
U.S.A.
Germany
C.S.A.
C.S.A.
C.S.A.
C.S.A.
U.S.A.
Germany
C.S.A.
Switzerland

though this may be related to the patient population studied, which is generally those with advanced refractory
disease. Ongoing approaches are evaluating gene therapy
in combination with chemotherapy.[241

P53
P53 is the most frequently mutated gene in human cancer,
with an up to 50% mutation frequency in solid tumors.
Most commonly. these genetic changes are missense
mutations in one allele, although deletions or chain termination mutations can occur.

Gene Therapy

375

Table 4 Oncology: phase I11 ongoing gene therapy clinical

trials as of February 1, 2001
Indication
Glioblastoma
Head and neck
Melanoma
Ovarian cancer

Gene

Number
of trials

Country

1
1
1

Multicountry
U.S.A.
U.S.A.

U.K., U.S.A.

HSV-TK
P53
HLA-B7/Beta
2 microglobin
P53

Key: HSV-TK, herpesvirus thymidine kinase

Table 6 Cardiology: phase I and I1 ongoing gene therapy

clinical trials as of February 1, 2001
Indication

Gene

Number
of trials

Coronary artery
disease
Coronary artery
disease
Peripheral artery
disease

VEGF

Finland

FGF

U.S.A.

VEGF

Finland, U.S.A.

Country

Key: VEGF, vascular endothelial growth factor; FGF, fibroblast growth

factor.

Because normal or wild-type p53 is important in cell

cycle regulation and apoptosis. restoration or modulation
of p53 function is under intensive investigation for cancer therapy, with the hypothesis that restoration of p53
function may make cancer cells more susceptible to
the effects of DNA damage inflicted by conventional
chemotherapy or radiotherapy and able to undergo apoptosis.r221Three main approaches are under evaluation.
First, there is virus-mediated gene transfer in which a viral
genome is engineered to contain foreign genes that are
expressed in the host cell genome after infection. Second,
there is the use of a cytolytic virus that can replicate only
in cells that lack p53 function, and by targeting such cells
could destroy tumors with mutant p53. Third, there is the
discovery or design of small n;olecules that can interfere
with the negative regulation of p53, pharmacologically
activating the p53 response.
A single clinical trial using wild-type p53 gene transfer
in nine patients with non-small cell lung cancer in whom
conventional treatment had failed has been reported.[251In
this study, the LNSX retroviral vector was injected di-

Table 5 Infectious disease: phase I and I1 ongoing gene

therapy clinical trials as of February 1, 2001
Indication
EBV and
CMV
HIV
HIV
HIV
HIV

Gene

Number
of studies

Country

CMV pp65

U.S.A.

HIV envhev

CD-zeta
TcR chimera
Antisense
to pol 1
Rev+pol 1

U.S.A.,
Switzerland
U.S.A.

U.S.A.

U.S.A.

Key: EBV. Epstein-Barr virus; CMV, cytomegalovirus; HIV, human

immunodeficiency virus.

rectly into the tumor either percutaneously with radiological guidance or via a bronchoscope. In situ hybridization and DNA PCR showed vector-p53 sequences in
posttreatment biopsies, and apoptosis was more frequent
in posttreatment than in pretreatment biopsies. No treatment-related toxicity was noted, and tumor regression
occurred in three patients. Further extensive trials of adenovirus encoding wild-type p53 are currently underway.
The DNA tumor virus adenovirus produces a 55-kDa
protein from the E1B region of its genome, which binds
and inactivates p53. It was hypothesized that an adenovirus lacking E1B would not be able to replicate in
normal cells but would in cancer cells lacking p53 function. For this reason, ONYX-015, an E1B gene-attenuated
adenovirus was compared with normal adenovirus in human and colonic cancer cell lines with and without p53
function. As expected, the ONYX-015 virus replicated as
efficiently as the normal virus in the cell line lacking
wild-type p53, but not in the line with normal p53 function.[261This vector is in early clinical trials.

~ a r d i o v a s ~ uDisease
l~r
Angiogenesis, or growth of new blood vessels, appears
essential in revascularization after myocardial infarction
as well as in treating coronary artery disease and peripheral artery disease. Therefore, cardiovascular gene therapy has concentrated on vascular endothelial growth
factor (VEGF) in these diseases[271(Table 6).

Familial homozygous hypercholesterolemia is a rare hereditary monogenic disorder caused by mutations of the
LDL receptor gene. Individuals have severe hypercholesterolemia associated with premature atherosclerosis. In
a single study, patients were treated with gene therapy

Gene Therapy

376

Table 7 Other ongoing gene therapy clinical trials as of

February 1, 2001
Indication

Amyotrophic
lateral sclerosis
Alzheimers disease

Gene

Studies

Countries

CNTF

Switzerland

Nerve
growth factor

U.S.A.

U.S.A.

U.S.A.

U.S.A.

1
1
1

U.S.A.
U.S.A.
Austria

Anemia of end-stage EPO

renal disease
Cubital tunnel
HIGF- 1
syndrome
Hip fracture
Parathyroid
hormone
Rheumatoid arthritis HSV-TK
Rheumatoid arthritis IRAP
Severe inflammatory IL-4 and IL-10
disease of rectum

Key: CNTF, ciliary neurotrophic factor; EPO, erythropoetin; HIGF,

human insulin-like growth factor: HSV-TK. herpesvirus thylimidine
kinase; IRAP, insulin responsive aminopeptidase.

with the LDL receptor. Expression of the receptor was

documented, but LDL cholesterol levels remained substantially elevated 3 to 6 months after gene transfer,
611 t27 vs. 550 t51 mg/dL, before and after gene therapy, respectively.[2x1

In a phase I evaluation, VEGF121.10 was administered

to 21 individuals by direct myocardial injection into an
area of reversible ischemia either as an adjunct to conventional coronary artery bypass grafting or as sole therapy via a minithoracotomy. There were no adverse
effects attributed to the gene transfer, and patients had
decreased angina.[291
Other trials of VEGF have been reported. A case report
demonstrated improvement in blood supply to an ischemic limb after intra-arterial gene transfer of a plasmid
encoding for VEGF.[301The use of a plasmid-based gene
delivery system, although inefficient, was reasonable in
this situation because VEGF is a potent secreted product.
A phase 1 trial of intramuscular delivery of a plasmidencoding VEGF in the setting of severe peripheral vascular disease was reported.[311 Gene transfer was performed in 10 limbs in nine patients with nonhealing
ischemic foot ulcers. Increased circulating VEGF levels
were demonstrated after intramuscular gene delivery. Various measures, including ankle-brachial index and magnetic resonance angiography, showed qualitative evidence
of improved distal flow in 8 limbs.

esistance (MDR)
In a therapeutic approach, stem cells may be isolated from
patients and genetically modified to express the MDR
gene.i321These cells are then retuned to the patient prior
to administration of chemotherapy, making the stem cells
resistant to chemotherapy.

ther Diseases
Formation of new blood vessels by the angiodan VEGF is
an experimental strategy for treating myocardial ischemia. The VEGF proteins function by interacting with
specific receptors on endothelial cells, which initiates a
cascade of events culminating in endothelial cell migration, proliferation, aggregation into tubelike structures,
and networking of the arterial and venous systems.[271
Gene transfer represents one approach to delivering an
angiogen to the heart in which the carrier DNA (cDNA)
coding for VEGF is delivered to the myocardium, with the
myocardial cells used to secrete the VEGF. Studies in
experimental animals have shown that replication-deficient, recombinant adenovirus (Ad) gene transfer vectors
are advantageous for delivery of angiogens such as
VEGF, in that Ad vectors provide a high transfection
efficiency, remain highly localized, and express VEGF
for a period of 1 to 2 weeks, which is sufficient to induce
collateral vessels to relieve the ischemia but not long
enough to evoke abnormal angiogene~is.~]

Gene therapy is under evaluation for many diseases,

ranging from rare inherited single gene defects to
common disease such as HIV. deafness, autoimmune
diseases, bone regeneration, and many others[4,33,341
(Tables 5 and 7).

The first death attributable to gene therapy occurred in

September 1999, when an 18-year-old patient with ornithine transcarbamylase deficiency died. apparently as a
direct result of the experimental gene therapy s t u d i e ~ . [ ~ * ~ ~ ]
This prompted two senate hearings and resulted in recommendation for implementation of new policies by the
Recombinant Advisory Council (RAC), Food and Drug
Administration (FDA) and NIH, which require earlier
review of researchers plans for monitoring safety and

Gene Therapj

quarterly meeting^.[^^-^^' A few of the safeguards implemented include thorough public evaluation of protocols
before investigational new drug assignment for FDA and
institutional review board (IRB) approval; the development of a single, uniform mechanism for reporting
adverse events to the RAC, FDA, and other relevant
agencies; establishment of a public database of all adverse
events; and nonparticipation of investigators with financial
interests in study outcomes in patient selection, the
informed consent process, and direct management of
clinical studies.
Further evaluation of this tragic event has identified
that vector-associated toxicity was not the sole cause for
this patients death. The FDA determined that human
subjects in this investigation were not adequately
protected and that there was substantial financial conflict
of interest. Subsequently, the NIH has discovered hundreds of unreported adverse events among volunteers enrolled in gene transfer experiments. These findings have
catalyzed broad examination of the entire clinical research
process, with the Secretary of Health and Human Services
calling for broad reforms in informed consent, clinical
monitoring, and conflict of interest.

Gene therapy is in its infancy. Early and ongoing success

in SCID, combined with promising studies in cardiovascular and oncology therapies, supports optimism for
these novel strategeis. However, several important issues
remain, including the best vector for transfer and appropriate protection for both patients and health care
providers. The Orkin-Motulsky report clearly stated that
significant problems remain in all basic aspects of gene
therapy. Major difficulties at the basic level include
shortcomings in all current gene transfer vectors and
an inadequate understanding of the biological interaction
of these vectors with the host.61 As such, the report
clearly identified key recommendations to ensure continued progress in this field. The recommendations were
to 1) continue research at the basic level to improve
vector design and studies that will further identify pathogenic mechanisms of disease, 2 ) improve trial design
with quantitative and qualitative assessment of gene
transfer and expression, 3) maintain adequate financial
support for gene therapy studies and promote interdisciplinary collaborations at the basic and clinical levels,
and 4) disseminate information to the public that clearly identifies limitations of the field as well as exciting
new discoveries.

377

Many new gene delivery vectors and protocols are

currently in developmental stages that aim to improve on
the earlier prototypes. The relatively small number of
vectors used in clinical trials underscores the complexity
of DNA delivery and our lack of knowledge about how
these macroparticulates are handled and expressed in the
human body. It is hoped that the recent reprioritization of
gene therapy studies will improve the design of vectors,
enhance our understanding of the biological interactions
between gene-carrying vectors and the body, eliminate
adverse events, and improve information gained from future clinical trials. Assuming these events occur, experts
still predict that gene therapy is still more than 5 to 10
years from routine use in patients.

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Cavazzana-Calvo, M.; Hacein-Bey, S.; dc Saint Basilc, 6 . ;

Gross, F.; Yvon, E.; Nusbaum, P.; Selz, F.; Hue, C.;
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PHARMACY PRACTICE ISSUES

Art

Wilkes Univcrsity, Willes-Barre, Pennsylvania, U.S.A.

I
All drugs that are approvcd for sale generally carry at least
two names. The drugs are given a proprietary or trade
name givcn by the company that first develops them.
These companies often are referred to as the innovator
company. The drug is igned a nonproprietary or generic
name, which is agreed to by the WHO lnternational
Nonproprictary Nomcnclature (INN) Committee and thc
U.S. Adoptcd Names Council (USAN). A new drug is
usually first marketed with some patent protection and at a
price that, at a minimum, recoups the cost of development
over the remaining life of the patent or othcr exclusivity
arrangement. Eventually, protection from competition is
lost to other pharmaceutical companies, often companies
or divisions of companies that specialize in marketing
off-patent drugs. These companies or divisions are called
generic companies. They can apply to thc appropriate
regulatory body such as thc Food and Drug Administration
(FDA) for permission to markct the same active ingredient
under its nonproprietary or generic namc. The generic
manufacturer is not required to do a cornpletc clinical trial
to prove effectiveness and safety because that has already
been well established for the drug. However, it is required
to show that the new drug product is equivalent to the
original drug product. For the purposes of this article, we
define the drug as the chemical that has the pharmacological effect and the drug product as a dosage form that
contains the drug and othcr ingredients or excipients that
allow thc formulation of thc dosage form. There is a large
economic incentive for the development of generic drug
products, cspecially for highly successful drug products.
The pharmnccutical company that first brought the product
to market maintains the price at the original level or higher
to continue the cash flow into the company. This allows
the other companies to develop a formulation of the drug
and to win approval to market with the knowledge that,
even at a fraction of the selling price of thc innovators
product, the company can make a good profit. Some
innovators defend their market share by arguing quality
and reliability. The FDA must act as an impartial arbitrator
of this debate. The debate is clearly about money, but is
argued in a scientific forum. The key qucstion is, Are we
Eizc\icloprdia of Clinical Pizar-incicy
DOI: 10.1081/E-ECP 120006417
Copyright 8 2003 by Marcel Dckker, Iiic. All rights reset-vccl

sure that the two products, if used in thc same way in the
same patient, will yield the same result. I f a drug product
is subject to this debate, thc innovator always says no
and the sccond and subsequent manufiacturers always say
yes. In the United States, the FDA scts the standards
against which the question is resolved, and scientists take
sides usually on the issuc of arc the current FDA
standards good enough. If the FDA givcs an A rating to
a drug product, it is in cffect telling the prescriber that the
drug product will yicld the same therapeutic and sideeffects profile as the innovator drug product. The Orangc
Book specifies the equivalence rating from the FDA.
Almost all generic drug products currently marketed are
rated A; the FDA has not approved a generic without an A
rating in decades. Finally, the consumer pays the price,
either in the unnecessarily high cost of drugs if
unnecessary studies are performed and gcneric competition delayed or in risky drug substitution if the FDA is too
relaxed in its standards. The tests required by the FDA
have changed over the years. They have become morc
proscriptive and are based on sound statistical grounds.
The FDA has also increased thc level of oversight of the
pharmaceutical companies that manufacture generic
equivalents of innovator products. Thus, the regulatory
process has become more stringent, and the level of
assurance that the public has that a generic product is both
safe and effective has gone LIP.The FDA has often statcd
that there are no known therapeutic failures from
switching among products that have been ruled as
equivalent by the FDA.

In the carly 1970s, most states had antisubstitution laws

that required the dispensing of the innovator product when
the prescriber wrote for a drug by trade name. Most
physicians had learned only thc tradc name of the drug
product, and these laws ensured that gcneric substitution
would be at a minimum (1). The Amcrican Pharmaceutical
Association (APhA) along with other groups pushed for
the repeal of these laws and opened the way for the growth
379

38

of the generic industry. The lack of bioequivalence data

available at that time led to the formation of the Generic
Drug Bureau within the Food and Drug Administration.
As a result of the efforts of that group, the FDA produced
a book, Appi'oved Drug Pi-oducts With Therapeutic
Equivalence Evaluations, in the late 1960s. This became
known as the Orange Book because of the cover color. The
book has been published annually with monthly updates.
The contents are now available on the FDA Website (2).
In 1984, the Drug Price Competition and Patent Term
Restoration Act was passed. This act. also known as the
Waxman-Hatch Bill of 1984. encouraged the development of new innovative drugs by established procedures,
extended patent rights, and facilitated the FDA approval
process for generic drugs (3). To address the first goal, the
law created a mechanism to extend the period of patent
protection for manufacturers of innovative new drugs
generally ensuring at least 5 years of market exclusivity
after approval. To address the second goal, the law
established an Abbreviated New Drug Application
(ANDA) for applications after 1962. Drugs chemically
equivalent to those previously approved by a full
application process need only be proven bioequivalent,
not clinically equivalent. Depending on the drug, proof of
bioequivalence can involve in vitro dissolution studies, in
vivo singie-dose bioavailability studies, in vivo multidose
bioavailability rtudies. or a combination of these.
However, in vitro dissolution studies alone are not
adequate proof of bioequivalence for purposes of an
ANDA.

The goal of the testing of generic products is not to

establish the clinical usefulness of the drug but only to
ensure that the generic product or new formulation has the
same relative bioavailability as or is bioequivalent to the
inno\ ator product.
Bioavailablity has been defined as a measure of the rate
and extent of absorption of a drug into the systemic
circulation after administration of a dosage form. An
intravenous i.v. dose is considered by definition to be
100% bioavailable. All other routes of administration will
produce a total bioavailability less than or equal to that of
the i.v. dose. Thus, only a drug that is completely absorbed
into the systemic circulation can have the extent of
bioavailability equal to the dose stated on the label. In
addition to the extent of absorption, the rate of absorption

Generic Drugs and Generic Equivalency

plays a key role when evaluating the potential therapeutic

impact of a particular dosage form. Knowledge of the time
to onset of drug action, which is directly related to rate of
absorption, is a significant concern, especially in acute
clinical situations such as asthma attack, hyperglycemic
shock, and pain.
The bioavailability of drugs from specific dosage forms
is affected by the nature of the inactive ingredients or
pharmaceutical excipients and the process used in its
formulation. (For additional information, see Bioavailability of Drugs and Bioequivalency in this Encyclopedia.)
When comparing similar dosage forms from different
manufacturers or different lots from the same manufacturer, it is most useful to determine the relative
bioavailability of the two products or lots. Some scientists
have attempted to establish an in vitro test that could
successfully predict in vivo bioavailability. However, to
date, none has been developed.
Pharmacokinetics means the application of kinetics to
drugs. It can be defined as the study of the time course and
fate of drugs in the body. Teorell is often given credit for
the origin of pharmacokinetics with his publications,
Kinetics of Distribution of Substances Administered to the
Body (4, 5 ) . This science is the theoretical support for the
use of bioequvalency testing to establish therapeutic
equivalence among dosage forms of the same drug. The
first approach to a pharmacokinetic understanding of drugs
in the body, called compartment analysis, considered the
body as a group of compartments through which the drug
must pass. The compartment itself does not exist but
represents the average of many processes that give rise to
the observed phenomenon. The size of the imaginary
compartment can be calculated and is useful in understanding the process of absorption, distribution, and
elimination or metabolism of the drug. Regardless of the
model used, a plot of the plasma concentration of the drug
versus time yields a curve that can be described by a
polyexponential equation. The area under that concentration-time curve (AUC) is directly related to the amount
of drug absorbed. The time to reach peak concentration
and the peak concentration itself are related to both the
dose and the rate of absorption.
An important limitation of compartment analysis is
that it cannot be applied universally to any drug. A
simpler approach that is useful in the case of
bioequavalency testing is the model independent method.
It is based on statistical-moment theory. This approach
uses the mean residence time (MRT) as a measure of a
statistical half-life of the drug in the body. The MRT can
be calculated by dividing the area under the first-moment
curve (AUMC) by the area under the plasma curve
(AUC) (6).

Generic Drugs and Generic Equivalency

381

(See other articles in this Encyclopedia for more detailed discussion of these subjects.)

Drug products often undergo bioavailability testing in the

early stages of development. Changes in formulation
necessitated by results of clinical trials or stability testing
or changes in the availability of excipients or changes in
suppliers of excipients often require that the manufacturer
perform a relative bioavalability or bioequivalency test to
ensure that subsequent lots of a product will yield the same
amount of active ingredient at the same rate as was
possible in earlier formulations.
Bioequivalency studies are usually performed on young,
healthy, male adult volunteers under controlled dietary
conditions and fixed activity levels. This is because the
goal of the study is not to establish the clinical usefulness
of the drug but only to ensure that the two formulations
have the same relative bioavailability or are bioequivalent.

When assessing bioequivalence, the following three

parameters that characterize the plasma or blood
concentration-time profile of the administered drug are
usually measured:

1. Peak height,,,C
,,
represents the highest concentration
of the drug in the systemic circulation;
2. Time to peak, t,,, represents the time for peak height
to occur after the drug was administered;
3. Area under the curve, AUC, represents the total
integrated area under the concentration- time curve.
The first two parameters are indicators of absorption
rate, whereas the third is directly proportional to the extent
of drug absorbed into the systemic circulation from the
dosage form. Figure 1 is an example of a concentrationtime curve for a single dose of drug to a subject.
Although it is theoretically possible to determine the
rate and extent of absorption of a drug by measurement
of the rate and extent of the appearance of the drug in
the urine, this is not considered as reliable a method for
evaluation of a drug products bioequivalency as are
blood level data. Thus, the studies commonly performed
to demonstrate bioequvalence fall into two catagouries:
single-dose and multidose or steady-state studies. There
are advantages and disadvantages to each. Single-dose
studies are less expensive and expose healthy volunteers

Fig. 1 Blood concentration curve.

to less drug during the course of the study. However,

these studies require more sensitive analytical methods
and have higher subject-to-subject variability. In both
cases, a cross-over study design is used to control for
sequence effects. The study is designed to control for or
take into account as many variables as possible. The
subjects are randomly assigned to groups. Blood
samples are obtained from each subject before dosing
and at fixed time intervals after dosing. Currently, the
data are then analyized using appropriate statistical
ANOVA. The results must meet FDA guidelines for
mean and 90% confidence interval for each of the three
key parameters. For oral solid dosage forms, the FDA
requires that for a product to be considered bioequivalent, the ratio of the parameter for the two products,
together with their 90% confidence interval, must fall
between 0.8 and 1.25, using log-transformed data. This,
in effect, means that drug products that differ by more
than 10% in their rate and extent of absorption will not
be approved as generic equivalents.

Two issues have been raised recently with regard to the

approval of generic drugs. The first has to do with the issue
of Narrow Therapeutic Index Drugs, and the second has
to do with the use of individual bioequivalence in place of
average bioequivalence. The former concern has been
addressed in detail by Drs. Benet and Goyan (7). They
concluded that narrow-therapeutic-range drugs were the
least likely to have therapeutic failures among generic

Generic Drugs and Generic Equivalency

382

drugs, with proof of bioequivalency. The use of average

bioequivalence data is under attack. This is because of the
concern that there might be a significant subject-byproduct interaction. Regulatory agencies now assume that
this is not the case (8). The advantage of using individual
bioequivalence studies is the reassurance that if subject/product interactions do occur, the study design would
control for them, and a more statistically valid measure of
the rate and extent of absorption of the drug from the two
product would be determined. Some of the disadvantages
associated with shifting from average to individual
bioequivalence testing are cost, numbers of subjects
needed, and diversity of the study population required.
[See other articles that address the impact of the new
metrics on the reliability and cost of the performance of
bioequivalence testing (9- 12).]

OMY

The modern generic drug industry in the United States

really only dates from the passage of the Waxman-Hatch
Act in 1984. Within 5 years of passage, generic drugs
captured 40% of the market for prescriptions written
inthe United States. Since that time, the generic drug
market share has stablized between 40 and 50% of the
prescriptions written. However, the dollars paid for
generic drugs are only 10% of the total sales of drugs in
the United States. That statistic alone tells us that the
consumer receives enormous benefit from the substitution of therapeutically equivalent generic drugs when
available.
A horrendous scandal hit the industry in the late 1980s,
wherein firms representing 75% of the production of the
generic industry pled guilty to one or more criminal
charges involving filing false applications with the FDA,
paying illegal gratuities to FDA personnel, and/or related
crimes to gain an unfair competitive advantage in the
emerging marketplace. Surprisingly, this scandal produced
only a small delay in the market share march of generic
drugs and only a temporary loss of consumer confidence in
generic products.
The scandal was tied to a phenomenon that still
dominates the business strategies of generic drug firms to
this day: the need to obtain approval to manufacture and
distribute before other firms enter the market. Because of
the commodity nature of the business and the relative
ease of entry into the industry, firms devote most of their
resources and managerial talent to obtaining first or second
approvals from the FDA for their products. Once a generic

drug has four or more competitors, it is no longer profitable

for additional generic companies to enter the market.
Generic drug manufacturers typically will continue to
manufacture drugs that produce little or no profit because
large purchasers that are their prime customers (chain
drugs stores, buying groups for smaller community
pharmacies, etc.) prefer to buy from companies that can
supply most of the common generic drugs. For example, if
a generic drug firm no longer produces amoxicillin
because it can make more money by shifting its antibiotic
production facilities to, for example, a cephalosporin drug
for which it has less competition, a large chain may chose
to buy its entire generic antibiotic line from another
company that supplies both.
The profitable generic drug companies are profitable
because they have found a strategy to maintain some
control over the price of their products. In the early years
(1984-1988), the best way to get first approval from
the FDA apparently was to be first to file, to get assays or
bioquivalence studies done on difficult to duplicate drugs,
or to find some way to get an expedited approval from
inside the agency. Unfortunately, this sometime involved
payoffs to FDA review chemists (those FDA experts
assigned the task of evaluating biostudy results, the
crucial piece of a generic drug application, remained
remarkably free of the scandal). More often, it involved
submitting false information to the FDA (including, in a
few cases, false biostudies). Many generic drug firms did
not survive the scandal, and others survived only after the
previous management and ownership were purged from
the firms.
For a short period, it was believed that the profitable
segment of the business involved not production but
distribution. After all, if commodity prices approach
marginal cost and the marginal cost of manufacturing
drugs is minimal, but the price to the consumer remains
significantly more than marginal, there must be middlemen somewhere making the money. Clearly, those
middlemen were not in the retail pharmacy where profits
continued to be squeezed. Distributors were thought to be
the new profit centers. But a funny thing happened on the
way to that particular bank.. . .
Consumers became outraged at the rapid increase in the
price of pharmaceuticals as the innovator companies (and
some generic firms) rushed to raise prices and as generic
drug company after generic drug company was pushed out
of the industry in the wake of investigations by a
Congressional committee and a federal grand jury.
Second, the Administration, in response to public concern
about the cost of pharmaceuticals, pressured the
pharmaceutical industry and forced lower prices and
significant rebates to the federal and state government

rugs and Generic Equivalency

programs that paid for drugs. Wholesale distributors of all

drugs subject to the federal rebates suffered.
Finally, the firms that thought they could profit most
from the scandal entered the market. These were
innovator firms, many of which had already played a
significant role in the distribution of generics.
Ultimately. the profit margins from generic drug sales
were not sufficient to carry the overhead of the branded
companies, and most left the market or returned to their
distributor role. Even in the case of the firms
manufacturing and marketing generic versions of their
own branded products, giving them significant advantage over the remaining pure generic firms in
developing and filing of the ANDAs with the FDA
and the added advantage of relatively less scrutiny from
the scandal-rocked agency, most had exited the
marketed by the end of the decade.
Some innovator firms entered the generic drug market
so that they could have a product line consistent with their
new business strategy: disease state management. This
strategy, a function of the rise of HMOs and the return of
the concept of scarcity to prescription drug dispensing,
was intended to involve the development of a continuum
of drug therapies for the treatment of a specific illness
(diabetes, depression, etc.), wherein the patient would be
tried on the older, less-expensive drug first and. if it did not
work. the next most cost-effective drug would be
administered and so on until the least cost-effective drug
would be the treatment of last resort. Unfortunately, the
branded companies that selected this strategy found
themselves competing with doctors. hospitals, and
insurance companies for control of the treatment regime
of individual patients, a losing proposition for the entity
with the least amount of information about and access to
the individual patient.
Another factor in reducing prices of all drugs that had
some form of competition was the rise of the HMO and its
pharmaceutical watchdog. the pharmacy benefit manager
(PBM). These PBiMs create a formulary of approved drugs
(drugs for which they would reimburse partially or fully)
based on bids from competing companies.
Much of the publics confusion regarding generic
drugs arose from a practice of the PBMs to pressure
doctors to substitute different chemical entities in the
same therapeutic class for the prescribed medicine. Such
a switch IS called a theraputic substitution as opposed to
the switching among manufacturers of therapeutically
equivalent drugs (generics and the innovator drug or
other FDA AB-rated substitutes). Therapeutic substitution involves a switch to a different drug, whereas
generic substitution involves a switch to the same drug
from a different manufacturer. If a patient is switched

383

between FDA AB-rated drugs, the FDA offers the

assurance that they can expect the same therapeutic
and side-effect profile as the brand drug or another
AB-rated generic drug. The FDA offers no such
assurance if the switch occurs among different drugs,
even if they are in the same therapeutic class. For
example, aspirin and Tylenol may be equally effective in
the treatment of headache, but the FDA makes no such
certification. whereas it makes exactly that certification
for Bayer aspirin and Safeway aspirin.
The dominance of the HMO (and related organizations) and their PBMs (and related organization types)
served to accelerate the substitution of generic drugs at
the turn of the 21st century. However, even that pressure could not slow the re-emergence of a high rate of
price increase, greater than consumer or comparable
wholesale prices as a whole, in prescription drugs.
Innovator companies learned that establishing very
high prices for breakthorough drugs could more than
compensate for the loss of patent protection on a highly
profitable drug.
Furthermore, the United States is the only developed
country in the world that has chosen not to explicitly control
the price of any drug product and has used its market power
as a huge buyer relatively sparingly. Consequently. U.S.
prices for drug products still under patent are usually
substantially above those charged anywhere else in the
world. Generic prices approach cost except for those few
generics that have managed to eliminate or limit for a
specific period competition from other generics.
Those generic drug firms that prospered in this
restrictive price environment all had one or more niche
drugs that were immune from corrosive price competition.
Some companies mastered a manufacturing process that
produced bioequivalent medicine that the innovator itself
found difficult to master lot to lot. Others took advantage
of certain exclusivity provisions in the law for those that
challenged a product patent in court, ostensibly to cover
the cost of litigation. In other cases, the settlement of those
cases provided some form of licensing or distribution
rights that permitted the sale of a generic product while the
patent was still valid. Finally, a fortunate firm might find
itself in possession of the exclusive right to purchase the
raw material from the only source available to generic
drug manufacturers.
All generic drug firms capable of generating the
necessary cash to develop and market new drugs are
moving toward that lucrative market. For the time being,
the United States has chosen to use the market mechanism
as its only important control on drug prices. Generics are
the competition, and competition is our only real form of
price control.

Generic Drugs and Generic Equivalency

384

According to the Congresslonal Budget Office (CBQ),

consumers saved $8- 10 billion in 1994 because of the use
of generic drugs. In that same 1998 report, CBO cited the
Waxman-Hatch Act, generic substitution laws passed by
the states, and government health programs as seminal
events leading to the acceptance of generic drugs and the
resulting savings.

5.

6.

I.
8.

Knoben, J.E.; Scott, G.R.; Tonelli, R.J. Overview of the

FDA Publication Approved Drug Products with Therapeutic Equivalence Evaluations. Am. J. Hosp. Pharm. 1990,
47 (12), 2696-2700.
Food and Drug Administration. Approved Drug Products
with Therapeutic Equivalence Evaluations; http://www.
fda.gov/cder/ob/ FDA: Rockville; Available from the
Government Printing Office: Washington, DC. 2000.
Weaver, L.C. Drug Cost Containment-The
Case for
Generics: Situation in the U.S.A. J. Soc. Admi. Pharm.
1989, 6 (l), 9-13.
Teorell, T. Kinetics of Distribution of Substances
Administered to the Body. 1. The Extravascular Modcs of

9.
10.
11.

12.

Administration. Archives Internationales de Pharmacodynamie et dc Therapie. 1937, 57, 205-225.

Teorell, T. Kinetics of Distribution of Substances
Administered to the Body. 11. The Intravascular Mode of
Administration. Archives Internationales de Pharmacodynamie et de Therapie. 1937, 57, 226-240.
Yamaoka, K.; Nakagawa, T.; Uno, T. Statistical Moments
in Pharmacokinetics. J. Pharmacokinet. Biopharm. 1978,
6 ( 6 ) , 547-558.
Benet, L.Z.; Goyan, J.E. Bioequivalence and Narrow
Therapeutic Index Drugs. Pharmacotherapy 1995, 15 (4),
433 -440.
Patnaik, R.N.; Lesko, L.J.; Chen, M.L. Individual
Bioequivalence. New Concepts in the Statistical Assessment of Bioequivalence Metrics. FDA Individual Bioequivalence Working Group. Clin. Pharmacokine. 1997,
33 (1). 1-6.
Midha, K.K.; Rawson, M.J.; Hubbard, J.W. Individual and
Average Bioequivalence of Highly Variable Drugs and
Drug Products. J. Pharm. Sci. 1997, 86 (1 i), 1193-1 197.
Snikeris,F.; Tingey, H.B. ATwo-StepMethodfor Assessing
Bioequivalence. Drug Inf. J. 1994,28 ( 3 ) , 709-722.
Holder, D.J.; Hsuan, F. A Moment-Based Criterion for
Determining Individual Bioequivalence. Drug Inf. J. 1995,
29 ( 3 ) , 965-979.
Mohandoss, E.; Chow, S.C.; Ki, F.Y. Application of
Williams Design for Bioequivalence Trials. Drug Inf. J.
1995, 29 (3), 1029- 1038.

PROFESSIONAL DEVELOPMENT

Virco L ' h Inc-., Rockville, Mnryland, U.S.A.

I
Approximately 7000 pharmacists serve the federal government in a variety of rolcs and organizations, including
the Department of Veterans Affairs (VA),the Department
of Defensc (DOD), and the U.S. Public Health Service
(PHS). Pharmacists in the uniformed services, Army,
Navy, Air Force, and PHS, may be either commissioned
officers or hired via the civil service system. Opportunities for clinical practice and research in the federal government represent a large, but relatively unknown option.

The VA health care system now includes 4000 pharmacists, 173 medical centers, nearly 670 outpatient and
community clinics, and 131 nursing home units. The VA
is affiliated with more than 1000 schools across the
United States, including pharmacy, medical, and dental
schools. Each year, approximately 100,000 health professionals receive training at VA medical centers. The VA
system has been a leader in opening new career pathways
for pharmacists that reward the achievement of exccptional skills. For example, pharmacists can receive increases in pay by complction of advanced degrees or by
ing the board certified pharmacothcrapy specialist
(BCPS) examination. There arc a number of programs to
provide additional training for VA pharmacists and transition them from distributive roles to clinical functions.
Veterans Affairs pharmacists serve in a number of
clinical roles including, but not limited to, pharmacistrun ambulatory clinics, members of intcrdisciplinary care
teams, patient education, pharmacokinetic evaluations,
therapeutic consultation, and research." These services
are providcd in various inpatient, long-term, and ambulatory paticnt care settings. Most clinical pharmacists
will have advanced professional degrees (M.S. or
PharmD.), postgraduate training, and/or sufficient professional experience. Clinical pharmacy specialists arc

'

Encjclopctiia of Cliiiical Phui-mucy

DOI: IO.IOXIIE-ECP 120006176
Published C 2003 h y Marcel Dekker, Iiic. A!I rights reserved

advanced practitioners who provide clinical services for

specialized services. These services include anticoagulation, psychiatry, geriatrics, diabetes, infectious diseases,
and medication refill. They also may have prescribing
authority within a defined scope of practice. There arc
185 pharmacy residency programs at VA medical centers, many with a strong emphasis on ainbulatory and
primary care.

The mission of the medical departments in the Army,

Navy, and Air Force is t o provide effectivc health care to
U.S. forces in times of conflict and to provide highquality health care in p e a ~ c t i m c . ' ~There
. ~ ' are currently
approximately 1500 pharmacists working in these units,
both as commissioned officers and civil service. Some
pharmacists within the armed services arc deployed with
troops to provide pharmacy services during training
missions or wars. Therefore, they must participate in
training exercises and workshops designed to simulate
these types of expericnces. Other pharinacists work at
military hospitals and outpatient clinics, providing more
traditional clinical pharmacy services. Pharmacists participate in a variety of clinical roles, including patient
rounds, drug information, and patient counseling. Some
pharmacists undergo a credentialing process that gives
them prescriptive authority and enables them to assumc
responsibility for the management of thc patient within
defined roles and limits. Armed services ambulatory care
pharmacists play activc roles in direct patient care within
such therapeutic areas as diabetes, asthma, hyperlipidemia, and hypertension.
Pharmacists within the Army are also members of a
bioterrorism readiness force that is prepared to respond
to medical emergencics arising from the terrorist use
of weapons of mass destruction. Many pharmacists
within thc armed services do not possess Pharm.
other advanced degrees, although therc is a strong coin385

Government, Clinical Pharmacy Careers in

356

mitment to support those individuals who pursue

additional education. There are a number of residency
and fellowship programs available to these pharmacists. and opportunities exist to attain a nontraditional
PharmD degree.

The PHS is organizationally part of the Department of

Health and Human Services.41Pharmacists are probably
most familiar with such agencies as the Centers for
Disease Control and Prevention (CDC). the Food and
Drug Administration (FDA), the Indian Health Service
(IHS). and National Institutes of Health (NIH). In addition, the PHS has memorandums of agreement with
the Federal Bureau of Prisons (BOP), Immigration and
Naturalization Service, and U.S. Coast Guard (USCG), to
provide primary health services. The Office of Emergency Preparedness and the National Disaster Medical
System are also located within the Department of Health
and Human Services.

rs d

r e v ~tnion

There are currently nine pharmacists who serve at the

CDC coordinating the CDC Drug Service, which distributes 13 special immunobiological materials and drugs
to physicians in the United States. Special biological and
antiparasitic drugs that the CDC distributes include botulism and diptheria antitoxin, bithionol. ivermectin. pentostam, and other medications with restricted usage in
the United States. These pharmacists also ensure procurement of drugs, maintenance of treatment investigational
new drug applications (INDs), and timely reporting to the
FDA. Other pharmacists who also possess a Masters
degree in Public Health perform epidemiology and field
work in foreign countries. The CDC has been charged to
maintain a stockpile of pharmaceuticals that can be immediately deployed in response to chemical or biological
terrorism events within the United States.

The FDA employs more than 250 pharmacists in all phases

of the agencys regulation of drugs, biologics. medical
devices, medical foods, and veterinary products. Pharmacists serve as reviewers for INDs. new drug applications
(NDAs), and generic drug approvals, evaluating the safety,

efficacy, packaging, and advertising of prescription and

nonprescription drugs. They are also involved in adverse
experience reporting and postmarketing surveillance, and
function in many other positions ranging from field inspector to project managers, which are the liaison between
the pharmaceutical industry and the FDA. Other pharmacists contribute to the FDA with respect to compendia1
standards, scientific investigations, manufacturing facility
inspections, and the FDAs research laboratories. In addition, they also work with expert advisory committees and
review panels. Most FDA pharmacists serve at the headquarters in Rockville, MD, but others are assigned to the
many regional, district, and local offices throughout the
United States that carry out inspection and enforcement
activities. A PharmD degree is preferred but not generally
required for many FDA positions.

Indian Health Service

The IHS employs more than 500 pharmacists who are
part of a health care team that provides comprehensive
care to 1.4 million Native Americans and Alaska Natives
in hospitals and ambulatory clinics in 34 states. The IHS
pioneered many of the clinical pharmacy services that
are now considered standard practice. Pharmacists have
direct access to the patients medical record to ensure
appropriateness of drug therapy, monitor for adverse
effects. and conduct activities in health promotion and
disease prevention. Indian Health Services pharmacists
have long been involved in expanded roles such as
primary care, and many have prescriptive authority under
medical staff protocols. They are actively involved in
drug selection, dosing. treatment, and evaluation of
therapy. Patient consultation has been an integral part
of the IHS pharmacy program for more than 30 years, and
private consultation rooms are used to promote effective
patient communication. The IHS offers three residency
programs: American Society of Health-System Pharmacists (ASHP)-accredited programs in pharmacy practice
and ambulatory care, and an American Pharmaceutical
Association (APhA)-accredited residency in community
pharmacy practice. The IHS also provides their pharmacists with the opportunity to pursue a PharmD degree
through a relationship with Idaho State University.

National institutes of
Opportunities for pharmacists exist in both the intramural and extramural programs. The extramural program accounts for nearly 90% of NIH funding and is

Government, Clinical Pharmacy Careers in

comprised of sites around the world, whereas the

intramural program is located on the NIH campus in
Bethesda, Maryland. The NIH Clinical Center is a 350bed hospital devoted exclusively to patients of the
intramural clinical research program. Its pharmacy is
supported by 50 pharmacists in various roles, including
nine clinical pharmacy specialists in the areas of
oncology, infectious diseases, critical care, bone marrow
and solid organ transplant, mental health, drug information, and ambulatory care. These pharmacists also serve
as principal and associate investigators in various NIH
studies. Clinical pharmacy specialists generally have a
PharmD degree and postgraduate training in residency
and/or fellowship programs. The staff also includes
pharmacists with expertise in drug formulation, study
design, analyticallquality control, and pharmacokinetics.
The NIH also offers four ASHP-accredited residencies.
There are also opportunities for radiopharmacists within
the NIH Clinical Centers Nuclear Medicine and Positive
Electron Tomography (PET) Departments.
The research program at NIH also uses pharmacists
in many of its 14 institutes. Pharmacists in the National
Cancer Institutes (NCIs) Pharmaceutical Management
Branch are involved in anticancer drug development,
protocol development, collection of clinical data, distribution of NCI investigational drugs and the Treatment
Referral Center. In addition, the intramural program of
the NCI has a pharmacokinetics laboratory where pharmacists perform basic and clinical research. The
National Institute of Allergy and Infectious Diseases
(NIAID) Division of AIDS pharmacists participate in
protocol development and implementation, and act as
consultants to more than 300 pharmacists involved in
NIAID-sponsored AIDS clinical trials.

The BOP employs more than 120 pharmacists who work

in both hospital and ambulatory settings in 99 prisons in
38 states. Pharmacists fill medication orders directly
from the inmates medical record, thereby having access
to full information on the patient. Pharmacists at the
BOP are significantly involved in monitoring compliance, managing drug therapy. ordering and interpreting
laboratory studies, and medication counseling for inmates in tuberculosis prophylaxis, mental health, HIV/
AIDS. and other more traditional chronic disease clinics.
Many pharmacists stationed in hospital settings have a
presence on mental health and medical/surgery floors,
round with physicians, and provide drug information
services to the medical staff. Pharmacists at the BOP are

387

also performing research in the area of patient counseling and compliance.

ast
Officers commissioned by the PHS deliver primary care
services to USCG members and their families at 26
shore-based sites. Sixteen active-duty, PHS- commissioned corps pharmacists are detailed to the USCG. In
the early 1990s, the USCG adopted the chart prescribing
and prescription dispensing model developed by the IHS.
The USCG pharmacy program is linked throughout the
United States to the DOD Composite Health Care System for computerized dispensing functions.

The PHS offers students in medicine, nursing, pharmacy,

and other allied health professions the chance to gain
career experience at sites throughout the United States
through a program called COSTEP. These salaried positions, available during vacation or elective time, provide
students with valuable experience and insight into career
opportunities within the PHS.

C
These programs represent the most common career paths
for pharmacists in the U.S. government. However, there
are additional federal agencies, such as the Centers for
Medicare and Medicaid Services, where pharmacists
serve in nontraditional roles. Although generally not
considered by pharmacy practitioners and students, the
federal government provides a number of innovative and
unique practice areas for clinical pharmacists.

* Pharmacy programs within the PHS and related links

http://www.hhs.gov/pharmacy/
* Links to numerous DHHS agencies
http:l/www. hhs.gov/agencies

Government, Clinical ~ ~ ~ a Careers

r ~ ain c ~

388
e

VA
http://www.va gov

U.S. Public Health Servicc Commi\sioned corps

http://www.usphr.gov
@

U.S. Army Pharmacy

http://armypharmacy .org
U.S. Air Force Pharmacy
http://www.af-pharmacicts. or&/

U S. Navy Pharmacy
http://navymedicine med navy. mil/navypharmacy

DOD Pharmacoeconomic Center

http://www.pec.ha. osd.mil/

NIH Pharmacy Department

http://www.cc.nih.gov/phar

@den, J.E.; Muniz. A,; Patterson, A.A.; Ramirez, D.J.;

Kizer, K.W. Pharmaceutical services in the department of
Veterans Affairs. Am. J. Health-Syst. Pharm.
761 - ~ ~ 7 6 5 .
2. Williams. R.F.; Moran. E.L.; Bottaro, S.D., 11; Dydek; G.J.;
Caouette. M.L.; Thomas, J.D.; Echcvarria. R. Pharmaceutical services in the United States army. Am. J. HcalthSyst. Pharm. 1997. 54 (7); 773-778.
3. Young, J.H. Pharmaceutical services in the United States
air force. Am. J. Health-Syst. Pharm. 11999, 54 (7), 783786.
4. Paavola, F.G.; Dermanoski, K.R.; Pittman. R.E. Pharmaceutical services in the United S
Service. Am. J. Health-Syst. Pharm.
772.
1.

PHARMACY PRACTICE ISSUES

ea
Templc University, PhiLidelphia, Pennsylvania, U.S.A.

Merc k RC Co. inc., Whitehouse S h l i o n , N e w Jersey, U.S.A.

I
It is quite fascinating how the organization, structure, and
financing of health care services can be so very diverse in
different countries around the world. One might think that
leaders and policymakers would be aware of each others
national health systems and, by emulating the best
features, that they would tend to move toward harmonization and greater similarity.
umptions is false. National hcalth
care systems vary widely and are more related to
variables in each country (1). In Fact, the hcalth system
in a given country is a mirror of how that society
functions at large. Health care delivery systems must be
compatible with thc: 1) economic system: socialist,
capitalist, or mixed; 2) political .system: major or minor
role of dcgree of government centralization; 3) wealth qf
the country: use of primary care facilities, access to
specialists and tertiary care facilities; 4) tmditinn.v and
conventions as ,seen in theiv history-fundamental,
visible things are difficult to change; 5) geography:
whether the majority of the population is located in a
few metropolitan arcas, with the remainder scattered in
rural areas, or whether the population is spread over
hundreds of islands; 6) injhtructure: roads, communication systems, and air service; and 7) extent of and
belicj in high teclznology (2).
There are other factors as well: the system from a
previous colonial power, extent of literacy and
education, and relationships with outside countries, to
name a few.

The remainder of this article examines the hcalth care

delivery cystem\ i n six very different countries. Even
though Canada and the United Statcs are similar countries
with a shared border and language and with open
1h:vcloprdicz o j Cliiiir.ol Phcir-nzcq
D01: 10.1081/E-ECP
120006421
Copyright 0 2003 by Mai-ccl Dekker, lnc. All rights reservcd

communication, their health care delivery systems could

not be any more diffcrent. Each side of the border is aware
of what happens on the other side, however, a series of
complex and powerful forces keep them moving in their
own directions.
We look at six countries very briefly in this article to
highlight the incredibly diverse approaches to health
service organization and financing. In essence, most health
systems fit into one of the following models:
State ownership and control-The best examples are
the British National Health Service and the Swedish
system in which clinics, hospitals, and most service
providers are owned and operated by the government
(3).
State health insurance program-Here,
the govcrninent is the sole or major payer.
the facilities and resources are in nongovcrnment
hands. This is the case in much of Europe (4).
Mixed system-This is seen in much of Asia and
Central America and usually where there is a small
wealthy class and a massive lower class. The lower
class receives care from public facilities, and the small
upper class uses private-sector, fee-for-service, and
self-paid care.
Other scenarios fit into this category as well. The
United States has several independcnt health care systems
including the military, veterans, Medicaid (a federal
program for the medically indigent), Medicarc (a federal
insurance program for those 65 years of age and older),
private-sector for-profit, and not-for-profit clinics, hospital chains, managed-care organizations, religious,
prison health, and university teaching facilities ( 5 ) .
4. Exclusively private sector-This category is shrinking as nations realize that health maintenance and
disease prevcntion/wellness are important to their
national goals of strength and productivity. Switzerland would still fit into this category, where most
health care resources are in private hands (6).
389

Health Care Systems: Outside the United States

390

anada
Organization
Canada uses a national health service, which provides
medical services and hospital care to its entire population.
The individual provincial governments operate health
plans that conform to national legislation but can differ in
various aspects. This Medicare program guarantees
comprehensiveness, universal access, portability, and
public administration (7).
Health Canada is the national, federal health agency;
however, the operation of health service provision is
delegated to the provincial governments, which control
virtually 100% of Canadas hospitals. There is a
gatekeeper primary health care system. with GPs (general
practitioners) or primary care family doctors serving as the
entry point. Access to specialists, diagnostic testing,
hospitals, and others is through the GP. Individual citizens
have the freedom to choose their own doctors, 95% of
whom are self-employed in private practice. The
provincial government pays these doctors on a fee-forservice basis.
The individual provincial governments offer different
supplemental benefits not covered by the national
Medicare program, such as drugs, dental care, and vision
care to the poor, elderly, and other specific groups.
Supplemental benefits for the typical, employed, and
nonelderly person come from the purchase of supplemental health insurance from private sources (8).

Further controls exist at the provincial level at which

each province maintains a published formulary of drugs
that are reimbursable along with the reimbursement level.
Quebec, observers perceive, lists nearly all new drug
products, whereas Ontario appears to be slow to list newly
approved products. Each province has additional control
mechanisms. Ontario requires the first generic drug to be at
least 40% less costly than the branded originator product.
Some components of the reference price system are seen in
British Columbia and Newfoundland.
There is growing harmonization among the provinces;
however. there is still no national, standardized, and
interchangeable list of drugs for ambulatory care use. In
hospitals, drugs that are administered are paid for by
Medicare. Each province has interesting and different
features in its drug benefit plan.
The Prince Edward Island plan pays for seniors; welfare
recipients; nursing home patients; and those with
rheumatic fever, diabetes, tuberculosis, multiple sclerosis,
AIDS, and several other conditions. New Brunswick has
an annual copayment cap for seniors and for organ
transplant recipients and for selected other patient
categories. A copayment is set at approximately 59
(Canadian) but is waived for some groups in Quebec,
along with an annual copay ceiling of $750.
Other interesting features of the Canadian system
include its 1998 mutual recognition agreement with the
EU, prohibition of prescription drug advertising to
consumers, a 20-year patent exclusivity period, and the
establishment of the PMPRB to ensure fair pricing of
medications (9, 10).

Pharmaceuticals
Canada created the Patented Medicine Prices Review
Board (PMPRB) in 1987 to guarantee that pharmaceutical products would not have excessive prices in
Canada. The board reviews prescribed and over-thecounter (OTC) prices and publishes annual guidelines
for manufacturers. Compliance with PMPRB guidelines
is voluntary; however. since 1993, the board has
the authority to reduce excessive prices and return the
excess amount to the government, and to punish the
manufacturer.
The PMPRB compares prices in Canada with those in
seven industrialized nations (France. Germany, Italy,
Sweden, Switzerland, the United Kingdom, and the United
States) to ensure that Canadian prices are in line with those
of comparable countries. There is some controversy that
existing drug products are well-controlled regarding
prices, but that such is not the case with newly introduced
pharmaceuticals.

frica

Organization
The Republic of South Africa (RSA) has a most diverse
health care environment, with world-class practice and
facilities in wealthy urban areas and some of the most
primitive care in poor remote villages, with a vast array
between these extremes. Primary care is now the focus of
the ANC government in an effort to correct years of
neglect and undemocratic practices under the earlier
apartheid-oriented regimes. Public health services are
being brought to the Black townships as rapidly as
resources permit (1 1).
However, there are virtually no funds for new drugs
against HIV infection in patients. a problem most prevalent
in the RSA. To maximize the value of its drugs budget, the
RSA has enacted legislation to create an Essential Drugs
List for the public sector, along with generic substitution
authority, the removal of some pharmacists unique

Health Care Systems: Outside the United States

professional privileges, and legislation permitting the

parallel importation of pharmaceutical products already
registered in the RSA. Obviously, this conserves resources,
stretching them for more patients, but this angers the RSA
and multinational pharma firms.
South Africa is still the wealthiest country in Africa,
with a (1997) GDP at approximately $130 billion. It must
be noted, though, that aggregate numbers hide massive
racial differences. It is improving, but the standard of
living for Blacks is yet only slightly better than it is in
neighboring countries, whereas whites enjoy a standard of
living similar to that found in North America or Western
Europe. An unemployment rate of over 30% (mostly among
Blacks) exacerbates the fiscal situation (12).
Routine immunizations for children, conforming to the
World Health Organization (WHO) recommended schedule is the governmental policy, but it is not yet
accomplished in all regions. Infectious diseases including
HIV remain a serious challenge. Planning and budgeting
for resource allocation are difficult because accurate
census figures do not exist. Total health expenditures
appear to be in the area of $300 per person per year. and it
is estimated that the private sector accounts for greater
than 50% of total expenditures.
Public-sector expenditures emphasize primary care,
lately, at the expense of tertiary care facilities. Privatesector spending is primarily through private *medical
schemes. These are nonprofit organizations supported by
employer associations and employees. There are slightly
fewer than 200 of these schemes, providing insurance and
care payment for nearly 3 million workers and their 5
million dependents (of a total estimated RSA population of
40 million). The largest area of medical scheme
expenditure is for medicines, which causes the pressures
on pharmaceutical pricing addressed below. After drugs,
the next largest expenditures are for private hospitals,
medical specialists, general practitioners, and dentists (13).
The RSA Department of Health (DOH) has totally
restructured the previous apartheid system of racial and
provincial health systems into a coordinated national
health program operated through health regions and local
health districts. Still, there are major differences in
knowledge, education, expectations. and wealth within
different subpopulations (14, 15).

Pharmaceuticals
Until recently, manufacturers were free to establish their
desired price for a drug. Wholesalers and retailers added
what they chose to reach the retail selling price for
medications. In 1997, a proposed scheme of prices extending
to the retailer was agreed on, but resistance was met from the
Pharmaceutical Manufacturers Association(PMA). In the

391

legislation, a pricing board composed of members selected

by the Minister of Health would establish prices for each
product and a maximum selling price. Public-sector primary
care drugs are reimbursed 100% by the government.
Hospital care outpatient drugs can have copayments. The
Essential Drugs List would be the core of what is to be
available at public facilities, but there appears to be a long
way to go before most of these agents will be regularly
available on a consistent basis at primary care centers or at
public hospitals (13).
The parallel importation of RSA-registered drugs
available at lower prices abroad is the basis for PMA
litigation against the Drug Legislation of 1997. In addition
to the price-setting committee, DOH efforts to encourage
the use of generic drugs has proven to be a source of
conflict. Other features of the new legislation bar
dispensing samples or making bonus payments to
dispensers of medicines; the creation of a Code of Ethics
for pharmaceutical marketing; and a series of safety
regulations, dealing primarily with limiting practice to
fully qualified and licensed professionals.
There is a fast lane for new drug approvals if the
product is already in at least one of the following
jurisdictions: the United Kingdom, Canada, United States,
Sweden, or Australia. Approxmately 85% (by value) of
pharmaceuticals go through the nearly 3,000 community
pharmacies. Yet, approxmately 80% of the population rely
on the public sector for drugs, received through clinics,
hospitals, primary care posts. or military facilities.
Although there is a 20-year patent period of exclusivity1
protection, the parallel imports option effectively defeats
this protection.
It will be interesting to see how the access to drugs,
price controls, and quality improvement forces will
interact and what the actual situation will be in South
Africa in the coming years, especially as the country
complies with intellectual property and World Trade
Organization policies and rules (16).

Japan

Organization
After North America and before Western Europe, Japan is
the second largest pharmaceutical market in the world. Its
population of 126 million spends $70 billion on
pharmaceuticals each year. On average, each Japanese
resident spends $2000 each year on health care with $550
of that on pharmaceuticals. Perhaps the primary single
features of the Japanese market are the above-average
proportion of elderly in the population and the higher than
usual consumption of drugs. It has been estimated that by
the year 2050, nearly 30% of the population will be older

Computer Software for Clinical ~ ' h ~ r m a cServices

y

218

Table 2

Installed base and functionality offered

a,

Computer Software for Clinical Pharmacy Services

219

Table 2 Installed base and functionality offered (Continued)

Functionality
Footnotes
1 Internet-based Medicare billing
and CMN documentationnlanagement system. Markets
served also include infiision
pharmacy
2 IVR system designed to Pandle
electronic prescriptions and
interface with central-processing
and central-fill systems
3 Chain cential management for
POS system
4 Installations represent primarily
large. long-term-care proiiders.
Also serve correctional institutions.
5 Database for front-store systems
6 Medication-compliance system.
7 Clinical drug data.
6 Chain centrai mananement for
POS system
9 Also systems to LTC market and
offers ASP service
13 Also have installations at military
locations.
11 Systems also installed in clinics,
correctional institutions. and
long-term-care facilities
12 Clinical drug data
13 Also serve HME pharmacy market. with biliing service that has
8,422 clients.
14 Aiso have systems installed in
veterinary practices.
15 Products use by Dept of
DefenseNA as well Company
seils software-driven warning
iabels
16 Company is dedicated soley to
tile long-term-care market
Installation figure represent 6,664
users serving in excess of 1 million LTC beds All functionalitv
offered is for long-term-care
pharmacy. Chain instaliations
represent long-term-care chain
providers.
17 Represents installations cf
barcode scanning fcr data entry
and verification
IS Company specializes in POS
s y s m s Chair central nianagement is for POS system.
19 Customized pricing service ior
retail pharmacy.
20 Chain central management
system will be released Nov
2001
22 Web design and management for
retail pharmacy. 1ns:allations
represenl CornerDrugstore com
sites.
23 A core product is an ASP service.
24 Data :onversion and databasemanagement sewices.
LEGEND
ii: = interface
r/a = 10" aijDlicaale
ris = no; spec lied
uid = dndei development

220

work, new and unique hardware challenges will be presented. Bandwidth to the home represents one of the greatest challenges for telecommuting. Services such as DSL
and cable modems offer potential solutions to this bandwidth problem. Productivity gains as high as 30 percent
are reported as an incentive for investigation of this area.

Computer Software for Clinical Pharmacy Services

of simply ignoring them. System oversight for monitoring

the potential of medication error should occur throughout
the process, beginning with point-of-prescribing through
point-of-administration. Bar codes and other technologies
will be needed to facilitate this process.

DOCUMENTATION
If one asks the question. What is my computer supposed
to be doing when Im providing pharmaceutical care?
the answer will not only describe the appropriate hardware
or device that matches the needs of the professional
providing the care, but should also describe the optimal
software that will support the provision of pharmaceutical
care. We define the point-of-care as the place where a
pharmacist provides pharmaceutical care to a patient or
assists a colleague (pharmacist, physician, or nurse) in the
provision of care. Many kinds of software available on the
market today focus solely on transaction processing, with
minimal decision support available through prospective
drug utilization review (DUR) modules.
Because the clinical environment demands real-time or
near-real-time decisions, a different kind of computer
support is required. Pharmacy is like other healthcare
disciplines in that we face the problem of having large
volumes of information but a lack of information services
that are able to translate this information into better outcomes for patients.r21A clinical practitioner requiring decision support wants this support to be presented in a
succinct manner that facilitates a timely response to the
problems routinely encountered in his or her practice.
Specific characteristics of successful decision-support
systems include the provision of patient-specific recommendations, delivery of measurable time savings, and
seamless integration into the daily work activities of the
clinical ~ e t t i n g . ~
Documentation
]
should occur as a byproduct of the interactions between clinical practitioners
and their patients or clients. Access to patient records
should not only be provided instantaneously through
electronic means, but the ability to customize the information provided into a format desired by the individual
practitioner should be allowed. When pharmacokinetic
calculations are required, known demographic values
such as body weight or serum creatinine levels should be
prepopulated into calculation variables.
Clinicians will often desire to examine historical data or
use relevant references, or primary or secondary literature
sources. The software design should include these aspects
at a minimum. When prospective drug utilization review
flags are presented, false positive warnings should be
minimal to prevent practitioners from getting in the habit

It has been said, If you didnt document it, you didnt

do it. In the litigious environment in which we live,
documentation is paramount to professional survival.
Without documentation, reimbursement can be challenged. Personnel reductions are almost assured without
documentation to demonstrate the impact of clinical
services. Without documentation, unnecessary redundancies and events will be exacerbated.
Ideally, documentation should occur as a natural byproduct of rendering care to patients. In these times where
the integration of care (care management) is being sought,
the ability of clinical software to access and populate a
clinical data repository is a key evaluation criterion.
Increasingly, integration with clinical practice protocols
is facilitating more effective and more comprehensive
delivery of care. A major question is, Will the patient and
the profession of pharmacy be best served by accessing,
on a read/write basis, an electronic medical record that is
seen by all other disciplines, or should pharmacists to
continue to have a pharmacy-specific software solution?
It may be mission critical to the profession for pharmacists to gain or maintain read/write privileges where
all pharmaceutical care contributions can be viewed by
all caregivers. Additionally. pharmacists will need to be
able to access diagnosis, laboratory, and other charted information such as demographics on a common medical
record. Thus, at a minimum, it will be necessary for all
pharmacy software to be able to be integrated into the
electronic medical records as they emerge.
Orthopedics has recognized the importance of measuring outcomes in terms of quality-adjusted life-years instead of length of implant survival.21Similarly, pharmacy
must implement software documentation solutions that
facilitate outcomes monitoring beyond cost savings.
Software is needed with the ability to calculate, in a costbenefit analysis, the clinical impact of pharmacist interventions as they affect therapeutic, financial, and humanistic outcomes. The current array of products could be
better integrated into documentation software to facilitate
tabulation of these data. With the power of the Internet to
manipulate data in a dynamic database, it would even be
possible for hospitals to compare their outcomes on a local,
regional, or national basis. Furthermore, the database could

Computer Software for Clinical Pharmacy Services

be utilized to gain new insights into additional interventions that could be implemented by clinical personnel.

Distribution software has had many years to evolve and

improve. Software that supports the provision of pharmaceutical care is still maturing. The provision of
pharmaceutical care is a process. Whether this provision
occurs in a community, health system, long-term care facility, or other pharmacy practice setting, there is a process that underlies each practice. The practice of pharmaceutical care begins with the appraisal of the patient.
Based on the findings of that appraisal, the pharmacist
will perform one or several interventions. Having documented an intervention, the pharmacist will then need
to evaluate the outcomes of these interventions. Once
the desired outcomes have been achieved and documented, a suitable follow-up and monitoring schedule should
be established.
Software that supports this process to the highest degree
should be sought, identified, evaluated, purchased, and
through user feedback, enhanced continually. The best-ofclass clinical software available helps pharmacists assure
that an efficient, comprehensive, and cost-effective rendering of pharmaceutical care is provided. Excellent pharmaceutical care software will be evidence-based in all
aspects of support, including practice protocols and decision support tools. Due to the importance of financial
outcomes, multiple aspects of care provision would be
covered by these applications, including n;edications,
nondrug therapies, steps for prevention, lifestyle issues,
and alternative medicine. The software would also include
suggested outcomes to be measured and appropriate
scheduling considerations.
Ideally. clinical software should help prompt practitioners through the provision of the care process. Automatic to-do lists will assure consistency in care provision.
Integration with all other aspects of the management and
distribution side of pharmacy practice must be assured so
that the coordination of care within a pharmacy operation is
assured. Prospective drug utilization review assets and
succinct decision-support resources should be internalized
within the software to minimize the necessity of using
multiple applications for every problem-solving exercise.
Again, measurement of the potential impact for pharmaceutical care interventions should be done as a byproduct of rendering care. This means that as a pharmacist
uses clinical software the application deductively calculates potential calamities that were averted and dollar
savings that were attained.

221

Thus far we have only focused on patient care clinical

software. An increasingly important alternative focus
would include population-based patient management.
Some health systems call this care management, and it is
largely a nursing-involved activity. Because pharmacists
use automation to a greater degree than other healthcare
disciplines, it is possible to generate a clinical data repository revolving around drug-related problems in a timelier
manner than is possible with a total system approach. Data
mining of this repository can yield significant management information resources on both a strategic and tactical
level. Selection of clinical software should never ignore
this population-based aspect of data analysis. Although
pharmacist involvement in this area is currently not as
widespread as it could be, there are many opportunities
available for expansion.

There are several complementary computer applications

that deserve mention. Part of the difficulty associated with
the increased documentation necessary from pharmacy can
be alleviated, in part, through the use of continuous speech
recognition applications. This chapter was authored using a
speech recognition program, which allowed the authors to
speak at 160 words per minute with about 99 percent
accuracy. It recognizes medical vocabulary and will allow
the user, after only a five-minute training session, to speak
directly into any Windows-based program.
Other applications that should be considered for integration involve access to tertiary literature sources
directly from the clinical application. The purpose of
information is to reduce uncertainty. The ability for the
pharmacist to access and validate decisions based on
evidence found in the literature is an important skill and
a necessary requirement for clinical software support.
This kind of support can be provided in palm-top form,
from network resources, and as intranet applications.
A movement is underway in medicine and nursing that
will allow a concept known as just-in-time continuing
education to become mainstream. When pharmacists need
to access reference information while solving a clinical
problem, it is appropriate that this activity be accredited
as continuing education. When pharmacists accumulate
one hour of this continuing education activity, a posttest
would be offered at a convenient time. A score of 75
percent would result in 0.1 CEUs being awarded.
Currently. WebMD is providing credit to physicians
who use its Web site to keep up with current issues in
medicine. Pharmacists will be the focus of a similar effort
if funding permits.

Computer Software for Clinical Pharmacy Services

222

Even though patients distrust the implications surrounding

their medical records being available electronically, the
benefits for this movement should outweigh the potential
risks. There are currently 14 layers of technology to help
ensure privacy, security, and confidentiality of the medical records of patients. Encryption, user tracking, biometric authentication. and other measures make it possible, beyond a reasonable certainty, to give patients the
assurance necessary for them to sign an informed consent
document allowing their records to be online. The basis
for moving forward in this effort will be founded on the
trust relationship between individual practitioners and
individual patients.
Research based on widespread use of electronic
medical records in three British hospitals has demonstrated that these records can be practical while ensuring
patient privacy. The first step taken was to develop an
access control list to identify which individual caregivers
are responsible for a patient, and therefore, can access his/
her records. The system also documents all occasions
when a record is accessed, whether or not information in it
was modified. As not all caregivers will be acknowledged
as providing care to a particular patient, certain users are
given override privileges that allow them to access
records when the system is not aware that they are,
indeed, providing care to this patient. The user is warned
that his actions are being documented when this override
procedure is used. The ability to collate enterprise-wide
clinical data has posed a problem in this system. When
caregivers want to gather data on a specific condition,
they are only able to gather information on those patients
under their care. This is an acknowledged limitation of
this current system. It is important to note that in the five
years this system has been in use, no patients have
requested a report of all accesses of their record.[41Again,
trust in caregivers translates into trust for the electronic
medical record.

replies, Oh, you must have seen our demo. One of the
first recommendations we make is, during an evaluation
of a piece of software, stop allowing the salesperson to
show you the power path way their software can solve
all of your problems. Each salesperson knows the best set
of circumstances to show off all of the unique features
available from an application.
We recommend, instead, that you build a matrix
whereby you will place competing systems in rows on the
matrix and place all of the features and benefits offered by
each system in the columns of the matrix. Next, devise a
rating system where 3 would equal excellent, 2 would
equal moderately available, 1 would equal minimally
available, and 0 would equal missing. A simple priority
system can help weight each feature by a priority to the
pharmacy operation. A calculation using feature score and
feature weight would help create a selection of the most
powerful application, with the greatest score identifying
the most suitable system from those compared. Subjective assessments of user-friendliness, screen designs, and
number of keystrokes necessary to perform the most
common tasks can be similarly evaluated.
In clinical applications, the best recommendation for
testing available applications would be to use a casebased methodology. We recommend that five or six
complicated cases, which would represent a cross section
of the patient population served by the pharmacy, be used
to test the application. In this way, the clinician will see
how the application performs throughout an entire care
process and avoid the power path demonstration. In this
information age, selecting clinical software is an extremely important task. The explosion of capabilities offered by the Internet can make the selection process both
exciting and confusing. A careful analysis of options will
usually be rewarded by better results, but wary buyers
need to prepare themselves to revisit the marketplace
more frequently than they might have in the past to identify innovative alternatives.

EN

There is an old joke about a man, who, upon approaching

the gates of heaven. sees that the people in heaven are
singing and playing harps, and the people in hell are
playing golf and tennis, and watching sports events.
Because he doesnt sing very well or play a harp, he
decides to opt for hell. Upon arriving, he finds himself
enveloped by fiery brimstone and demons that are poking
him with their pitchforks. He sees the devil walking by
and asks where all the golfing and tennis went? The devil

1. Capron, B.; Kuiper, D. The vendor relationship. Manuf.

Syst. 1998, (Suppl. A), 14-16.
2. Hurwitz, S.R.; Slawson, D.; Shaughnessy, A. Orthopaedic
information mastery: Applying evidence-based information tools to improve patient outcomes while saving
orthopaedists time. J. Bone Jt. Surg. Am. 2000, 82-A
(6). 888-894.
3. Payne, T.H. Computer decision support systems. Chest
2000. 118-S ( 2 ) , 47S-52S.
4. Denly, I.; Smith, S.W. Privacy in clinical information systems in secondary care. BMJ 1999, 318 (7194), 1328-

1330.

PHAKMACY PRACTICE ISSUES

Council a n Credentialing i n Pharmacy, Washington, D.C., U.S.A.

Pharmacist credentialing has become a topic of important

discussions in the profession of pharmacy in recent years.
These discussions, inherently complex, have sometimes
been further complicated by the lack of a common lexicon. The situation is understandable. Many different
words are used to describe the process by which pharmacists are educated, trained, licensed, and otherwise
recognized for their competence and achievements. Many
different organizations-public and private-are involved
in assessing pharmacists knowledge and skills, granting
credentials, and accrediting programs and institutions.

The purpose of this paper is to create a common frame of

reference and understanding for discussions concerning
pharmacist credentialing. It begins with definitions of several terms that are essential to any discussion of credcntialing. This is followed by a short section highlighting
thc importance of credentialing to pharmacists. The next
three sections, which form the body of the paper, discuss
in detail the thrcc types of credentials that pharmacists
may earn:
Credentials needed to prepare for practice (ix., academic degrees).
Credentials needed to enter practice (i.e., licensurc)
and to update professional knowledge and skills (i.e.,
relicensure) under statc law.
Credentials that pharmacists voluntarily earn to
document their specialized or advanced knowledge
and skills (i.e., postgraduate degrees, certificates,
certification).

site, whether the credential is voluntary or mandatory, the

credentialing body, and the agency that accredits the program. Particular attention is givcn to pharinacist certification programs, an area that has engendered much of the
current interest in pharmacist credentialing.
The paper also includes a brief section on credentialing
of pharmacy supportive personnel. It concludes with two
appendices. Appendix A contains a comprehensive glossary of key terms relating to pharmacist crcdentialing.
Appendix B is an alphabetical list of organiations involved in pharmacist credentialing and program accreditation. The list contains names, addresses, and uniform
resource locatoi-s (URLs).

Credentialing in Pharmacy has been created by the

Council on Credentialing in Pharmacy (CCP), a coalition
of 1 1 national pharmacy organizations founded in 1999 to
provide leadership, standards, public information, and
coordination for professional voluntary credcntialing
programs in pharmacy. Founding members of the CCP
include the following organizations:
e

e
0
0

8
0

Academy of Managed Care Pharmacy.

American Association of Colleges of Pharmacy.
American College of Apothecaries.
American Collcge of Clinical Pharmacy.
American Council on Pharinaceutical Education.
American Pharmaceutical Association.
American Society of- Consultant Pharmacists.
American Society of Health-System Pharmacists.
Board of Pharmaceutical Specialties.
Commission for Certification in Geriatric Pharmacy.
Pharmacy Technician Certification Board.

Each of these sections contains, as applicablc,

infhrmation aboul the credential awarded, the training

Copyright CC 2000 by the Council on Crcdentialing in Pharmacy.

Fncyclopeifici o j Clinicid Phavmric?
DOI: 10.108I/E-tCP 120006315,
Publishcd 2003 by Marcel Dckkcr, Inc. All rights reserved

Dixxssions of credentialing are often complicated by a

lack of common under4tanding of key terms and thc contexts in which they are u4ed. To clarify these misunder223

224

standings, one must first distinguish between processes

(e.g., credentialing) and titles (a credential). Distinctions
must also be made between processes that focus on individuals (e.g., credentialing and certification) and those
that focus on organizations (accreditation). Finally, it is
essential to understand that for practicing pharmacists,
some credentials are required (e.g.. an academic degree
or a state license), while others are earned voluntarily
(e.g., certification).
Beyond these distinctions, it is also necessary to
understand the definitions of the words that commonly
come up in discussions of credentialing and to be able to
distinguish the sometimes subtle differences among them.
A comprehensive glossary of such words and their definitions appears in Appendix A. The following definitions are provided here, because an understanding of these
terms is a prerequisite to any meaningful discussion of
credentialing in pharmacy.
A credential is documented evidence of a pharmacists
qualifications. Pharmacist credentials include diplomas, licenses, certificates, and certifications. These
credentials are reflected in a variety of abbreviations that pharmacists place after their names (e.g.,
Pharm.D. for doctor of pharmacy, an earned academic degree; R.Ph. for registered pharmacist.
which indicates state licensure; and acronyms such as
BCNSP for Board-Certified Nutrition Support Pharmacist, which indicates that an individual has demonstrated advanced knowledge or skill in a specialized area of pharmacy).
Credeiztialing is the process by which an organization
or institution obtains. verifies, and assesses a pharmacists qualifications to provide patient care services.
Accreditatiori is the process by which a private association. organization, or government agency, after initial and periodic evaluations, grants recognition to an
organization that has met certain established criteria.
A certificate is a document issued to a pharmacist
upon successful completion of the predetermined level
of performance of a certificate training program or of a
pharmacy residency or fellowship.
A statement of continuing education credit is a document issued to a pharmacist upon participation in an
accredited continuing education program.
Certification is a voluntary process by which a nongovernmental agency or an association grants recognition
to a pharmacist who has met certain predetermined
qualifications specified by that organization. This formal recognition is granted to designate to the public
that this pharmacist has attained the requisite level of
knowledge, skill, or experience in a well-defined, often

Credentialing in Pharmacy

specialized, area of the total discipline. Certification

usually requires initial assessment and periodic reassessments of the individuals qualifications.

Credential and credentialing, like the words

creed and credence, derike from the Latin verb
credere, which means to trust, to entrust, or to
believe. A pharmacists credentials are indicators that he
or she holds the qualifications needed to practice the
profession of pharmacy and is therefore worthy of the
trust of patients, of other health care professionals, and of
society as a whole.
In the profession of pharmacy, the interest in credentials has been catalyzed in recent years by several factors.
First among them is the pace of change and the increasing
complexity of health care. A second factor is the pharmacists expanding clinical role. Interest in credentialing has
likewise been stimulated by the growing trend toward specialization in pharmacy practice and by the need to document the pharmacists ability to provide specialty care.
Another contributing factor has been the need to help
ensure lifelong competence in a rapidly changing, technologically complex field. The need to provide a means of
standardization of practice has also had a role. Such a
motivation was key, for example, to the development of
the Federal Credentialing Program. which is creating a
national database of health professionals that will include pharmacists.
Finally, economic realities enter the picture. Pharmacists who are providing cognitive services or specialized
care need to be reimbursed for the services they provide.
Payers rightfully demand validation that pharmacists are
qualified to provide such services. Credentials, and in
many cases, more specifically, certification, can help
provide the documentation that Medicare and Medicaid,
managed care organizations, and other third-party payers
require of pharmacists today and in the future.

Pharmacist credentials may be divided into three fundamental types:

a

The first type-college

and university degrees-is
awarded to mark the successful completion of a
pharmacists academic training and education.

225

Credentialing in Pharmacy
a

The second type-licensure

and relicensure-is
an
indication that the pharmacist has met minimum requirements set by the state in which he or she intends
to practice.
The third type of credential-which may include advanced degrees and certificates-is awarded to pharmacy practitioners who have completed programs of
various types that are intended to develop and enhance
their knowledge and skills, or who have successfully
documented an advanced level of knowledge and skill
through an assessment process.

These three paths to pharmacist credentialing are illustrated in Fig. l . The sections that follow provide information on each of the credentials offered in pharmacy,
the credentialing or accreditation body involved, whether
the credential is mandatory or voluntary, and other related information.

Credential earned: Bachelor of Science degree in

Pharmacy; Doctor of Pharmacy degree.

Credential awarded by: School or college of pharmacy.

Accreditation body f o r professional progrums in pharmacy: American Council on Pharmaceutical Education (ACPE). The U S . Department of Education has
recognized the ACPE accreditation of the professional
degree program in pharmacy.

Until July 1, 2000, an individual who wished to become a pharmacist could enroll in a program of study that
would lead to one of two degrees: a bachelor of science
degree in pharmacy (B.S.Pharm. or Pharm.B.S.) or a
doctor of pharmacy (Pharm.D.) degree.
As of 1998, two-thirds of all students studying in
professional programs in pharmacy were enrolled in
Pharm.D. programs. The Pharm.D. degree became the
sole degree accredited by ACPE for pharmacists'
entry into practice in the United States, as of July 1,
2000, with the institution of new ACPE professional
program accreditation standards. Pharm.D. programs
typically take six years to complete and generally
involve two years of preprofessional coursework and
four years of professional education. A few programs

ractic
Relicensure
(State Boards and NABP)
Continuing Education programs (ACPE*)

Pharmacists
Doctor of Pharmacy
(Pharm.D.) Degree (ACPE*)
Usual Format:
2 yr pre-pharmacy
4 yr pharmacy
Non-traditional option for BS
graduates

Licensure
(State Boards of
Pharmacy and
NABP*)

Education (Optional)
Additional Education &Training (optional)
Advanced degrees
M.S.

Ph.D.
Training
Residency (ASHP)
Traineeship (ASHP*)
Fellowship (ACCP' AACP")
Certificate programs (ACPE*)
Continuing Education programs (ACPE*)

Certification (optional)
Specialty (BPS*)
Non-specialty (CCGP*)
Disease management (NISPC')
Multidisciplinary(various*)

Technicians
EducationiTraining
(ASHP*)

Fig. 1 U.S. pharmacy credentials and oversight bodies. (*Oversight bodies are described in text.)

Credentialing in Pharmacy

226

offer the professional education over three years of fulltime education.

B.S. level pharmacists who have been in the workforce
may also return to a college or school of pharmacy to earn
the Pharm.D. degree. These programs, which are tailored
to the individuals background and experience, may follow nontraditional pathways; however, they must produce the same educational outcomes as does the entrylevel Pharm.D. degree.
State boards of pharmacy require a Pharm.D. or B.S.
degree from a program approved by the boards (almost
always an ACPE-accredited program) for a candidate to
be eligible to take the state licensing examination. A listing of accredited professional programs offered by colleges and schools of pharmacy is published annually by
the ACPE, and is available on the ACPE web site (www.
acpe-accredit.org) .

Entering Practice and Updating Professional

Knowledge and Skills
4

e
0

Crederztials earrzed: Licensure as registered pharmacist (R.Ph.); relicensure.

Credential awarded by: State board of pharmacy.
Licensure process overseen by: State regulatory
authorities.

Before a graduate of a school or college of pharmacy

can practice pharmacy in the United States, he or she must
become licensed. The licensure process is regulated at the
state level by the boards of pharmacy.
Candidates for licensure in all states but California
must pass the North American Pharmacist Licensure ExaminationTM(NAPLEXE), a computer-adaptive, competency-based examination that assesses the candidates
ability to apply knowledge gained in pharmacy school
to real-life practice situations. California administers a
unique examination process. Most states also require
candidates to take a state-specific pharmacy law examination. Currently, 36 states use the Multistate Pharmacy
Jurisprudence ExaminationTM (MPJETM), a computeradaptive assessment that tailors each examination to address the pharmacy law and regulations of the state in
which the candidate is seeking licensure.
Both the NAPLEX and the MPJE are developed by
the National Association of Boards of Pharmacy (NABP)
for use by the boards of pharmacy as part of their assessment of competence to practice pharmacy. Development of these examinations is directly related to
NABPs mission, which is to assist its member boards
and jurisdictions in developing, implementing, and en-

forcing uniform standards for the purpose of protecting

the public health. The NAPLEX and MPJE examinations are administered by appointment, daily, throughout the year, at a system of test centers located in all
50 states.
In addition to the NAPLEX and MPJE, some states
require a laboratory examination or an oral examination
before licensure is conferred. All state boards also require
that candidates complete an internship before being licensed. The internship may be completed during the candidates academic training or after graduation, depending
upon state requirements.
State licensure is an indication that the individual has
attained the basic degree of competence necessary to
ensure the public health and welfare will be reasonably
well protected. The names of individuals who have
received a license may use the abbreviation R.Ph. (for
registered pharmacist) after their names.
Nearly all state boards of pharmacy also require that
registered pharmacists complete a certain number of
continuing education units (CEUs) before they can renew
their licenses. The CEUs must be earned through participation in a continuing education (CE) program whose
provider has been approved by the American Council on
Pharmaceutical Education (ACPE). The symbol used by
the American Council on Pharmaceutical Education to
designate that the continuing education provider is apNote that ACPE approves providers of continuing
education, not individual CE programs. CEUs may be
secured by attending educational seminars, teleconferences, and meetings; reading journal articles; or completing traditional home study courses or computer-based
education programs. Receipt of a satisfactory score on an
assessment that is created by and submitted to the CE
provider is sometimes required as a documentation of
completion of a CE program. ACPE publishes an annual
directory of approved providers of continuing pharmaceutical education, which is available on the ACPE
web site (www.acpe-accredit.org).
Licensure and relicensure are mandatory for pharmacists who wish to continue to practice their profession.
In their regulatory role, state boards of pharmacy are
ultimately responsible to the state legislature.

Developing and Enhancin

Knowledge and Skills
Pharmacy practitioners who wish to broaden and deepen
their knowledge and skills may participate in a variety of

227

Credentialing in Pharmacy

postgraduate education and training opportunities. They

include the following:

Academic postgraduate education and training

Pharmacists who wish to pursue a certain field of study
in depth may enroll in postgraduate masters or doctor
of philosophy (Ph.D.) programs. Common fields of
study for masters candidates include business administration, clinical pharmacy, and public health. Common
fields for Ph.D. studies include pharmacology. pharmaceutics, pharmacy practice, and social and administrative sciences.

A fellowship is an individualized postgraduate program that prepares the participant to become an independent researcher. Fellowship programs, like residencies,
usually last one to two years. The programs are developed
by colleges of pharmacy, academic health centers, colleges and universities, and pharmaceutical manufacturers.
There is no official accreditation body for fellowship
programs; however, the American Association of Colleges of Pharmacy and American College of Clinical
Pharmacy have issued guidelines that are followed by
many fellowship program directors.

Certificate Training Programs

0
0

0
0

Credential earned: Residency certificate.

Credential awarded by: Residency training program.
Program accreditation: The American Society of
Health-System Pharmacists (ASHP). (independently
or in collaboration with other pharmacy organizations).

ASHP is the chief accreditation body for pharmacy

practice and specialty residency programs in pharmacy.
A total of 505 programs nationwide now hold ASHP
accreditation. ASHP also partners with other organizations, including the Academy of iLlanaged Care Pharmacy, the American College of Clinical Pharmacy, the
American Pharmaceutical Association. and the American
Society of Consultant Pharmacists, in accrediting residency programs.
The majority of pharmacists who pursue residency
training do so in the area of pharmacy practice. These
residencies sometimes focus on a particular practice setting. such as ambulatory care. Pharmacists may also pursue specialty training in a certain topic (e.g., pharmacokinetics), in the care of a specific patient population (e.g.,
pediatrics). or in a specific disease area (e.g.. oncology).
Residency programs last one to two years. The typical
training site is a practice setting such as an academic
health center, a community pharmacy, a managed care
organization, a skilled nursing facility, or a home health
care agency.
The Health Care Financing Administration (HCFA), an
agency of the federal government, recognizes residency
accreditation bodies within the health professions.

0
0
0

Credential eamed: Fellowship certificate.

Credential awarded by: Fellowship training program.
Program accreditation: No official accreditation body.

Credential earned: Certificate of Completion.

Credential awarded by: Educational institutions and
companies, pharmacy organizations, and others.
Provider accreditation: American Council on Pharmaceutical Education.

A certificate training program is a structured and systematic postgraduate continuing education experience for
pharmacists that is generally smaller in magnitude and
shorter in duration than degree programs. Certificate programs are designed to instill, expand, or enhance practice
competencies through the systematic acquisition of specified knowledge, skills, attitudes, and behaviors. The
focus of certificate programs is relatively narrow; for
example, the American Pharmaceutical Association offers
programs in such areas as asthma, diabetes, immunization
delivery, and management of dyslipidemias.
Certificate training programs are offered by national
and state pharmacy organizations and by schools and
colleges of pharmacy and other educational groups. The
programs are often held in conjunction with a major
educational meeting of an organization. The American
Council on Pharmaceutical Education (ACPE) approves
providers of such programs. The symbol used by the
ACPE to designate that a certificate training program is
provided by an accredited provider is

KPE

Several pharmacy organizations, including the American College of

Clinical Pharmacy. the American Society of Health-System Pharmacists,
and the American Pharmaceutical Association, award the honorary title
of Fellow to selected members as a means of publicly recognizing
their contributions to the profession. A Fellow of ASHP, for example,
may write FASHP for Fellow of the American Society of HealthSystem Pharmacists, after his or her name. The two uses of the word
fellow-one
denoting an individual participating in a postgraduate
training program and the other denoting receipt of an honorary titleshould be clearly distinguished.

Credentialing in Pharmacy

228

and skills of those who are certified do, in fact, reflect competence.
Traineeships, in contrast to certificate training programs,
are defined as intensive, individualized, structured postgraduate programs intended to provide the participant
with the knowledge and skills needed to provide a high
level of care to patients with various chronic diseases and
conditions. Traineeships are generally of longer duration
(about five days) and involve smaller groups of trainees
than certificate training programs do. Some are offered
on a competitive basis, with a corporate sponsor or other
organization underwriting participants costs. Pharmacy
organizations currently offering traineeships include the
American College of Apothecaries, the American Society of Consultant Pharmacists, and the American Society of Health-System Pharmacists Research and Education Foundation.

Certification is a credential granted to pharmacists and

other health professionals who have demonstrated a level
of competence in a specific and relatively narrow area of
practice that exceeds the minimum requirements for licensure. Certification is granted on the basis of successful
completion of rigorously developed eligibility criteria that
include a written examination and, in some cases, an
experiential component. The certification process is undertaken and overseen by a nongovernmental body.
The development of a certification program includes
the following steps:
Role delineation. The first step is to define the area in
which certification is to be offered. This is done
through a process called role delineation or task
analysis. An expert panel of individuals in the proposed subject area develops a survey instrument to
assess how practitioners working in the area rate the
importance, frequency, and criticality of specific activities in that practice. The instrument is then sent to a
sample of pharmacists who are practicing in that field.
Development of content outline. On the basis of responses to the survey, a content outline for the certification program is developed.
Preparation of examination. The written examination
component of the certification program is developed
on the basis of the content outline.
Other activities. Appropriate measures are taken to
ensure that security and confidentially of the testing
process are maintained, that the examination and eligibility criteria are appropriate, and that the knowledge

A professional testing company typically assists in

the development of the role delineation and the examination to ensure that the examination meets professional standards of psychometric soundness and legal defensibility.
Celtifying agencies for pharmacists only
Three groups-the Board of Pharmaceutical Specialties,
the Commission for Certification in Geriatric Pharmacy,
and the National Institute for Standards in Pharmacist
Credentialing-offer certification to pharmacists.

oard of P ~ a ~ m a c @ u ~p@cial~@s
cal
lished in 1976 by the American Pharmaceutical Association, BPS is the only agency that offers certification at
the specialty level in pharmacy. It certifies pharmacists in
five specialties: nuclear pharmacy, nutrition support pharmacy, oncology pharmacy, pharmacotherapy, and psychiatric pharmacy. As of June 2002, nearly 3500 pharmacists held BPS certification, distributed across the five
specialties as follows:
Nuclear Pharmacy-47 1
Nutrition Support P h a r m a c y 4 2 5
Oncology Pharmacy-288
Pharmacotherapy-1843
Psychiatric Pharmacy-387
Pharmacists who wish to retain BPS certification must
be recertified every seven years.
The recognition of each specialty is the result of a
collaborative process between the Board and one or
more pharmacy organizations, which develop a petition
to support and justify recognition of the specialty.
This petition must meet written criteria established by
the BPS.
The BPS is directed by a nine-member board that
includes six pharmacists, two health professionals who
are not pharmacists, and one publickonsumer member. A
specialty council of six specialist members and three
pharmacists not in the specialty direct the certification
process for each specialty.
BPS examinations are administered with the assistance
of an educational testing firm, resulting in a process that is
psychometrically sound and legally defensible. Each of
the five specialties has its own eligibility criteria, examination specifications, and recertification processes. All

229

Credentialing in Pharmacy

five examinations are given on a single day once a year in

approximately 25 sites in the United States and elsewhere.
In 1997, BPS introduced a method designed to recognize focused areas within pharmacy specialties. A
designation of Added Qualifications denotes that an
individual has demonstrated an enhanced level of training
and experience in one segment of a BPS-recognized specialty. Added qualifications are conferred on the basis of a
portfolio review to qualified individuals who already hold
BPS certification. The first added qualification to receive
BPS approval was infectious diseases, within the pharmacotherapy specialty.

Commission for Certification in Geriatric Pharmacy

(CCGP). In 1997, the American Society of Consultant
Pharmacists (ASCP) Board of Directors voted to create
the CCGP to oversee a certification program in geriatric
pharmacy practice. CCGP is a nonprofit corporation that
is autonomous from ASCP. It has its own governing
Board of Commissioners. The CCGP Board of Commissioners includes five pharmacist members, one physician
member, one payer/employer member, one publickonsumer member, and one liaison member from the ASCP
Board of Directors.
Pharmacists who meet CCGPs requirements are
entitled to use the designation Certified Geriatric Pharmacist, or CGP. As of June 2002, approximately 800
pharmacists have earned the CGP credential. Pharmacists who wish to retain their CGP credential must recertify every five years by successfully completing a written examination.
CCGP contracts with a professional testing firm to
assist in conducting the role delineation or task analysis
and in developing and administering the examination. The
resulting process is psychometrically sound and legally
defensible; it also meets nationally recognized standards.
The CGP certification exams are administered twice a
year at multiple locations in the United States, Canada,
and Australia. CCGP publishes a candidate handbook that
includes the content outline for the examination, eligibility criteria for taking the examination, and the policies
and procedures of the certification program.
National Institute for Standards in Pharmacist Credentiding (NZSPC). The NISPC was founded in 1998 by
the American Pharmaceutical Association, the National
Association of Boards of Pharmacy (NABP), the National
Association of Chain Drug Stores, and the National
Community Pharmacists Association. The purpose of
NISPC is to promote the value and encourage the adoption of National Association of Boards of Pharmacy dis-

ease-specific examinations as the consistent and objective

means of documenting the ability of pharmacists to provide disease state management services.
NISPC offers certification in the management of diabetes, asthma, dyslipidemia, and anticoagulation therapy. At the time of its founding, the organizations immediate objective was to design a process that would
document the competence of pharmacists providing care
for patients with these disease states. The NISPC creential was first recognized in the state of Mississippi,
where it was used to enable pharmacists to qualify for
Medicaid reimbursement as part of a pilot project in that
state. The NABP developed the competency assessment
examinations and oversees their administration. As of
June 2002, 1340 pharmacists hold NISPC certification:
771 in diabetes, 314 in asthma, 120 in dysiipidemia, and
135 in anticoagulation therapy.
The NISPC tests are administered nationally as computerized examinations and are available throughout
the year.

Multidisciplinary certification programs

Some certification programs are available to professionals
from many health disciplines, including pharmacists.
Areas in which such certification programs are available
include diabetes education, anticoagulation therapy, pain
management, and asthma education. Some of these programs are still in the early stages of development. Several
of these providers are listed in Appendix B; however, the
information is not intended to be exhaustive.

e
A pharmacy technician is an individual who assists in
pharmacy activities that do not require the professional
judgment of a pharmacist. For example, pharmacy technicians may accept orders from patients, prepare labels,
enter drug information into the pharmacys computer system, and retrieve medications from inventory. As pharmacists assume an increasing number of clinical roles,
pharmacy technicians are taking more and more responsibility for distributive functions in pharmacies in
all settings.
The exact functions and responsibilities of pharmacy
technicians are defined by state laws and regulations and
are also determined by the willingness of pharmacists to
delegate the nonjudgmental activities of their practice.
Pharmacy technicians always work under the supervision
of a licensed pharmacist.

230

Credentialing in Pharmacy

The education and training. certification. and continuing education of pharmacy technicians are similar in some
ways to those of pharmacists.

raini
Most pharmacy technicians today have been trained on
the job, either formally or informally. As the responsibilities of pharmacy technicians grow, however, more and
more individuals are enrolling in formal training programs. These programs are generally affiliated with a
community college, a four-year college, a hospital. or
another health care organization. Graduates of these programs may be awarded an associates degree or a certificate of completion.
ASHP is the accreditation body for pharmacy technician training programs. Sixty programs were accredited
as of 1999.

n
State boards of pharmacy oversee the registration of
pharmacy technicians. Practices differ substantially from
state to state.

The Pharmacy Technician Certification Board (PTCB)

was established in 1995 as a national voluntary certification program for pharmacy technicians. Its founders were
the American Pharmaceutical Association, the American
Society of Health-System Pharmacists, the Illinois Council of Health-System Pharmacists. and the Michigan Pharmacists Association.
In collaboration with testing experts, the PTCB
developed a national examination, the Pharmacy Technician Certification Examination (PTCE). The examination is designed to assess the candidates knowledge
and skill base for activities that are most commonly performed by a pharmacy technician, as determined by a national task analysis.
The Board administers the PTCE three times a
year at more than 120 sites across the nation. A technician who passes the PTCE is designated as a Certified Pharmacy Technician (CPhT). As of June 2002,
more than 100,000 pharmacy technicians have earned
PTCB certification.
Pharmacy technicians must renew their certification every two years. To qualify for recertification,
they must participate in at least 20 hr of pharmacyrelated continuing education that includes an hour of
pharmacy law.

These definitions have been developed by a variety of

organizations involved in credentialing and are generally
accepted by those in the pharmacist credentialing arena.

Ac~reditat~on:The process whereby an association

or agency grants public recognition to an organization that
meets certain established qualifications or standards, as
determined through initial and periodic evaluations.
Certificate Training ogram: A structured, systematic postgraduate educ on and continuing education
experience for pharmacists that is generally smaller in
magnitude and shorter in duration than a degree program.
Certificate programs are designed to instill, expand, or
enhance practice competencies through the systematic acquisition of specific knowledge, skills, attitudes, and performance behaviors.
: Adjective that is used to describe an
individual who holds certification and that is incorporated into the name of the credential awarded that
individual. For example, someone who has earned BPS
certification in oncology is a Board-Certified Oncology Pharmacist.

Certificate: A certificate is a document issued to a

pharmacist upon successful completion of the predetermined level of performance of a certificate training
program or of a pharmacy residency or fellowship. See
also statement of continuing education credit.
Certification: The voluntary process by which a
nongovernmental agency or association formally grants
recognition to a pharmacist who has met certain predetermined qualifications specified by that organization.
This recognition designates to the public that the holder
has attained the requisite level of knowledge. skill, or
experience in a well-defined, often specialized, area of
the total discipline. Certification entails assessment, including testing, an evaluation of the candidates education and experience, or both. Periodic recertification is
usually required to retain the credential.
Clinical privileges: Authorization to provide a specific range of patient care services. See also Privileging.
etence: The ability to perform ones duties
accurately, make correct judgments, and interact appropriately with patients and with colleagues. Professional
competence is characterized by good problem-solving and
decision-making abilities, a strong knowledge base. and
the ability to apply knowledge and experience to diverse
patient-care situations.

Credentialing in Pharmacy

Competency: A distinct skill, ability, or attitude that

is essential to the practice of a profession. Individual
competencies for pharmacists include, for example,
mastery of aseptic technique and achievement of a
thought process that enables one to identify therapeutic
duplications. Pharmacists must master a variety of
competencies in order to gain competence in a profession.
Continuing education: Organized learning experiences and activities in which pharmacists engage after
they have completed their entry-level academic education
and training. These experiences are designed to promote
the continuous development of the skills, attitudes, and
knowledge needed to maintain proficiency, provide
quality service or products, respond to patient needs,
and keep abreast of change.

231

Scope of practice: The boundaries within which a

health professional may practice. For pharmacists, the
scope of practice is generally established by the board
or agency that regulates the profession in a given state
or organization.
~ t ~ t e ~ of
e ncontinuing
t
education credit: A document issued to a pharmacist upon completion of a
continuing education program provided by an organization approved by the American Council on Pharmaceutical Education.
Traineeship: A short, intensive, clinical, and didactic postgraduate educational program intended to provide
the pharmacist with knowledge and skills needed to provide a high level of care to patients with specific diseases
or conditions.

Credential: Documented evidence of professional

qualifications. For pharmacists, academic degrees, state
licensure, and Board certification are all examples
of credentials.
Gredentialing: 1) The process by which an organization or institution obtains, verifies, and assesses a pharmacists qualifications to provide patient care services;
2) The process of granting a credential (a designation
that indicates qualifications in a subject or an area.)

Pharmacy organizations

Fellowship: A directed, highly individualized postgraduate program designed to prepare a pharmacist to

become an independent researcher.

Academy of Managed Care Pharmacy (AMCP)

100 North Pitt Street, Suite 400; Alexandria, Virginia
22314; (800) 827-2627
www .amcp.org

License: A credential issued by a state or federal body that indicates that the holder is in compliance with minimum mandatory governmental requirements necessary to practice in a particular profession
or occupation.

American Association of Colleges of Pharmacy

(AACP)
1426 Prince Street; Alexandria, Virginia 223 14-2841;
(703) 836-8982
www .aacp.org

Licensure: The process of granting a license.

Pharmacy technician: An individual who, under
the supervision of a licensed pharmacist, assists in
pharmacy activities not requiring the professional
judgment of the pharmacist.
Privileging: The process by which a health care
organization, having reviewed an individual health care
providers credentials and performance and found them
satisfactory, authorizes that individual to perform a specific scope of patient care services within that organization.

American College of Apothecaries (ACA)

P.Q. Box 341266; Memphis, Tennessee 38184; (901)
383-81 19
www.acaresourcecenter.org
American College of Clinical Pharmacy (ACCPJ
3101 Broadway, Suite 380; Kansas City, Missouri
64111; (816) 531-2177
www.accp.com

esidency: An organized, directed, postgraduate

training program in a defined area of pharmacy practice.

American Council on Pharmaceutical Education

(ACPE)
20 North Clark Street, Suite 2500; Chicago, Illinois
60610; (312) 664-3575
www.acpe-accredit.org

Registered: Adjective used to describe a pharmacist

who has met state requirements for licensure and whose
name has been entered on a state registry of practitioners
who are licensed to practice in that jurisdiction.

American Pharmaceutical Association (APhA)

2215 Constitution Avenue, NW; Washington, D.C.
20037-2985; (202) 628-4410
www.aphanet.org

232

Credentialing in Pharmacy

American Society of Consultant Pharmacists (ASCP)

1321 Duke Street; Alexandria, Virginia 22314-3563;
(703) 739-1300
www.ascp.com

Board of Pharmaceutical Specialties (BPS)

2215 Constitution Avenue, NW; Washington, D.C.
20037-2985; (202) 429-7591
www.bpsweb.org

American Society o j Health-System Pharmacists

(ASHP)
7272 Wisconsin Avenue; Bethesda, Maryland 208 14;
(301) 657-3000
w ww .ashp.org

Council on Certification in Geriatric Pharmacy

(CCGP)
1321 Duke Strcct; Alexandria, Virginia 223 14-3563;
(703) 535-3038
www.ccgp.org

National Association of Bourds of' Pharmacy (NABP)

700 Busse Highway; Park Ridge, Illinois 60068; (847)
698-6227
www.nabp.net

National Asthma Educator Certificntion Board

American Lung Association
1740 Broadway; New York, New York 10019-4374;
(212) 3 15-8865
www.lungusa.org

National Association of Chain Drug Stores (NACDS)

413 N. Lee Street, P.O. Box 1417-D49; Alexandria,
Virginia 223 13- 1480; (703) 549-300 1
www.nacds.org
Nutional Community Pharmacists Association (NCPA)
205 Daingerfield Road; Alexandria, Virginia 223 14;
(703) 683-8200
www.ncpanet.org

National Certfication Board f o r Diabetes Educators

(NCBDE)
330 East Algonquin Road, Suite 4; Arlington Heights,
Illinois 60005; (847) 228-9795
www.nbcde.org

Certification bodies for pharmacists or pharmacy

technicians (may be multidisciplinary)

National Institute jbr Standards in Pharmacist Credentialing (NISPC)

P.O. Box 1 9 10; Alexandria, Virginia 223 13-1910;
(703) 299-8790
www.nispcnet.org

Anticoagulation Forum
88 East Newton Street, E-113; Boston, Ma\\achusetts
021 18-2395; (617) 638-7265
www.acorum.org

Pharmacy Technician Certification Board (PTCB)

221 5 Constitution Avenue, NW; Washington, D.C.
20037-2985; (202) 429-7576
www.ptcb.org

PKOFFSSIONAL DEVELOPMENT

Pharmacists havc bccn practicing in critical care since the

1970s when the new breed of clinical pharmacists were
expanding the horizons of care to include more than dispensing services. Thcse early practitioners recognized, as
we do today, that critically ill patients are treated with a
large number of different drugs that have significant alterations in their pharmacokinctics and pharmacodynaniics,
and great potential for drug misadventure.
Today, a growing numbcr of pharmacists practice exclusively in critical care settings. They are recognized
membcrs of the critical care team, along with the intensivist, nurses, dietitians, respiratory thcrapists, and others.
The exact numbcr of critical care pharmacists is not
known, but more than 450 pharmacists are membcrs ofthe
Society of Critical Care Medicinc (SCCM). This number
niay only represent a fraction of the total number because
many other pharmacists work in critical care satellites and
provide a broad range of pharmaccutical care serviccs.

The 1985 textbook, Iructice of Criticd Cure Pharmacy

was the gateway for many young practitioners. This book
contained chapters written by many of the groundbreaking practitioners in critical care. These chapters dctailed
the roles these and other influential critical care practitioncrs had developed and served as a primer for practice
in various intensive care units (ICU). These clinicians
deserve recognition for this and othcr contributions to the
dcvelopment of critical care pharmacy practice in a
variety of practice settings: Dave Angaran, MS (cardiovascular); Deborah Armstrong, PharmD (pediatric); Joyce
Comer, PharmD (medical); Gary Cupit,PharmD (pcdiatric
and neonatal); Joseph Dasta, MS (surgical); Robert
Elenbaas, PharmD (emergency medicine); Thomas Majerus, PharmD (trauma); and Christine Quandt, PharmD
(neurosurgical). These same practitioners fostcrcd the
cxpansion of the specialty through pharmacy residcncy
and fell ow ship training programs.

Eizcylopediu (fClinirnl Phoi-inrzcy

DOI: 10.108I /L-IiCP 12000622h
Copyright C 2003 by Marcel Ilcltkcr, Inc. All rights reserved

The need for ongoing education in a rapidly evolving

specialty led these practitioners to the SCCM, an organization whose rncmbership includes critical care practitioners from cvery discipline. As the number of pharmacist
members grew, a section was formed within SCCM in
1989, and its rncmbership has expanded progressively.
Although the pharmacy organimtions, the American College of Clinical Pharmacy (ACCP) and American Society
of Health-Systems Pharmacists (ASHP) havc scctions or
interest groups devoted to critical care, the SCCM has been
a focal point for the organizational activity of many of these
pharmacists. Many critical care pharmacists have made
significant contributions to thcse national organizations
through service o n the governing boards and committees.
Bart Chernow, MD, a mcmber of SCCM, was very
influential in the initiation o f thc Clinical Pharmacy and
Pharmacology Section of SCCM. His textbook on critical
care pharmacology included a chapter entitlcd, The Role
of the Pharmacist in Caring for the Critically 111 Patient.2 This was a vehicle to introduce thc benefits of
the pharmacist as a member of thc critical carc team to
critical care physicians. Critical care physicians have been
strong advocates for the role of the critical care pharmacist, were essential champions for the early practitioners,
and continue Lo be today. The SCCM recognizes the critical care pharmacist as an esscntial member of the multidisciplinary ICU team. Thesc guidelines recommend
that pharmacists provide pharmaceutical care through monitoring of dosing, adverse drug reactions, drug interactions, and education to create cost-optimized regimens. In
addition, the guide1ines also recognize thc important role
of critical care pharmacists in the care of the most complex
patients treated in tertiary care centers. The SCCM also
includcs a permanent position for a critical care pharmacist
on its governing council.
Additional recognition of the importance of the critical
care pharmacist has been the sclection of numerous pharmacists as fellows of the American College of Critical
Carc Medicine (ACCM). This designation is awarded to
critical care practitioners who have demonstrated a high
level of practicc, rcscarch, education, and service to SCCM
and their local organizations.
233

234

Pharmacists have contributed to our understanding of

the needs of the critically ill patient through descriptive
reports characterizing patterns of drug utilization. In
surgical and trauma patients, an average total of 7.6 and
9.1 medications per patient were reported, respectively.[4951
These data reaffirm reports that a growing number
of medications are used in ICU patients, from an average
,~]
of 4.2 to 7 rt 4.6 drugs per patient in general I C U S . [ ~ In
1988, the pharmacoeconomic impact of the large number
of medications used in surgical ICU patients was significant, averaging 13.6% of total hospital charges.[']
Hazards of these complex drug therapy regimens are
becoming well documented. Concern with medication errors is a frequent topic in the medical and lay literature."]
A general adult ICU reported that a medication error was
made in more than 50% of the patients, but the overall
error rate was low, detected in 2.2% of the doses dispensed or administered."'] However, this unit reported a
generous 1:1 nurse-to-patient ratio and relied on a retrospective medical record review to detect errors. Current
staffing patterns with 1:2 or 1:3 nurse-to-patient ratios are
becoming more common and may adversely affect error
frequency. Higher rates have been detected in other studies, due to differences in the definition of an error and
the method of detection. New therapies and technologies
may increase the risk of critical errors.["] The ability of
the pharmacist to reduce medication errors and adverse
drug events has been reported.[12' Pharmacists participating on physician rounds on a part-time basis were shown
to decrease all adverse drug events and, in particular, to
decrease preventable adverse drug events by 66%."'] The
pharmacist primarily detected prescribing errors such as
incomplete orders, incorrect doses or frequency, and therapy duplication; however, the pharmacist also avoided
inappropriate drug selection. Alternative therapies were
recommended that were safer (avoided a drug interaction
or allergy) or less expensive. Participation of a pharmacist
in the medication ordering process in a teaching hospital
appears to be essential to avoid prescribing errors.
Pharmacists have used avoidance of medication errors
to justify expanding services. A pediatric critical care satellite was opened to reduce the rate of errors from a total
of 17.4% in an intensive care nursery and 38% in a pediatric ICU."31 A large number of the errors (86.5%) occurred with medications possessing a high potential for
serious adverse consequences.
Avoidance of medication administration errors is another potential contribution of critical care pharmacists. A
multicenter analysis of medication errors from five ICUs
revealed that medication errors occurred most commonly
with vasoactive agents and ~edative-analgesics.['~~
Incorrect infusion rate was the most common error. The overall

Critical Care Pharmacy Practice

error rate was 3.3% (187 of 5744 observations), which is

lower than previously reported. The majority of the
errors caused no harm, but some required additional
patient monitoring or intervention. Other errors were
related to omission of doses or administration at an incorrect time. Critical care pharmacists observed these
medication errors during their routine daily activities.
The presence of these trained specialists may have influenced the number and type of errors. The process in
this report differs from prior observational studies where
a trained observer recorded medication administration
practices and recorded errors. However, calculation of
infusion rates was identified as an area for potential
quality improvement.

Pharmacists have developed specialty practices in every

facet of critical care and emergency medicine. These include burn, cardiac care, cardiovascular surgery, medical,
neurological, neurosurgical, renal, respiratory, surgical,
trauma, and pediatric and neonatal critical care. Pediatric
specialty units in the same areas may also have pharmacists dedicated to those units. Descriptive reports of their
contributions to these units have been p ~ b l i s h e d . [ ' ~ - ~ ~ ]
Although many of these practitioners work for larger
hospitals or have academic appointments, there is a growing number of pharmacists focusing on critical care patients in smaller hospitals. In 1989, a survey of hospitals
with >lo0 beds demonstrated that 34% of medium-size
hospitals had pharmacy satellites, as did 61% of large
hospitals.[241 The majority (76%) of pharmacists who
staffed these satellites held BS degrees. However, onethird of the pharmacists spent more than 50% of their
day providing clinical services. Hopefully, this level of
pharmacist involvement has been maintained or has
grown since the early 1990s. Although not a complete
measure, the number of critical care pharmacists who are
members of SCCM has grown progressively from approximately 80 in the early 1990s to the current number of
more than 450 pharmacist members. It is hoped that this
reflects a larger number of specialty practitioners in critical care.
The majority (63.2%), of critically ill patients are cared
for in hospitals without full-time or consultative intensivi~ts.''~]Patients are more likely to be cared for by their
primary physician or a single or multiple consultants
(pulmonary or cardiology), although hospitalists are becoming more available to care for ICU patients (internal
medicine specialists who care for hospitalized patients
full-time). An intensivist is a physician who is board

235

Critical Care Pharmacy Practice

certified in critical care but may have received their initial

medical training in medicine, surgery, anesthesia, or pediatrics. Board certification is achieved through the
subspecialty organizations after completion of a written
examination. The SCCM model of critical care is that of
an intensivist-led multidisciplinary team. An organized
critical care team has been a predictor of improved patient
care.[261Despite the apparent benefit of the intensivist-led
team, workforce projections predict a significant manpower shortfall by 2020, due to a relatively constant
supply but an increasing demand for critical care serv i c e ~ . [Critical
~ ~ ] care pharmacists may have increasing
opportunities to affect the care of these patients as a result
of this imbalance.

CH IN C R I ~ I C A LCARE
There are many challenges to performing research in a
critically ill patient. Informed consent may be difficult to
obtain if there is a narrow window for therapy initiation.
The ICU population may have numerous other injuries or
organ dysfunction that would disqualify the patient. Finally, an adequate number of patients may be difficult to
recruit. As a result, animal research models have been used
by critical care pharmacists to develop the framework for
clinical trials and control the large number of patient variables present in a critically ill patient.
Numerous avenues exist for critical care research.
Critical care pharmacists have contributed to the understanding of pharmacotherapy of multiple disease states
and organ systems. Evaluation of pharmacokinetics and
pharmacodynamics in the critically ill patient has facilitated the design of therapeutic regimens in these complicated patients. For example, the variations in hepatic
metabolic rate following head trauma or hemorrhagic
shock have been c h a r a c t e r i ~ e d However,
. ~ ~ ~ ~ ~ much
~ ~ additional research is needed to further characterize the impact of changes in organ function on phannacokinetics in
this complex and heterogeneous population.
Clinical case reports of unusual treatments or response
to therapy have presented a plethora of questions that
remain to be answered. Case series and descriptions of
experience with treatment protocols or the impact of
pharmacist interventions are useful contributions to the
literature. Evaluation of economics and outcomes has
been an important area of research in critical care. The
critically ill patient patient typically receives a large
number of different and often expensive medications, and
is monitored with expensive devices. Pharmacists have
characterized various aspects of the cost of care, although
comprehensive pharmacoeconomic outcome research is

difficult to accomplish in complex patients where numerous factors can influence outcome, but is essential to the
integration of novel therapies and improved utilization of
existing agents.
Critical care pharmacists have also been active in the
area of collaborative disease-state management and quality improvement projects, and have documented the impact of these on patient outcome. Pharmacists often take a
leadership role in these efforts. Examples of the impact of
these programs include reductions in the use of laboratory
cost saving through improved antibiotic utilization,"sl improved utilization of sedative and neuromuscular blocking a g e n t ~ , [ ~ limproved
-~~I
monitoring of
sedation, and avoidance of adverse drug
Training in critical care research is available through
fellowships cosponsored by the pharmaceutical industry
through organizations such as SCCM and ACCP, as well
as through a number of clinical training centers.

K ~ O W L ~ D
BASE
~ E
Although critical care is considered a specialty area, there
is a challenge to define the body of knowledge encompassed by this field. Critical care patients as a whole are a
very heterogeneous group. As a result, many institutions
provide care for a more homogenous group of patients in
geographically distinct units. Whether these patients are in

Table 1 Important components of critical care pharmacist

knowledge base for adult and pediatric patients
Pharmacokinetic alterations in the critically ill
Analgesia, sedation, neuromuscular blockade
Cardiovascular pathology and therapeutics
Endocrine pathology and therapeutics
Gastrointestinal pathology and therapeutics
Hemodynamic monitoring/manipulation
Hepatic pathology and therapeutics
Hematologic pathology and therapeutics
Infection control/antimicrobial therapy
Inflammatory injury/multiple organ system dysfunction
Neurological pathology and therapeutics
Nutritional support
Patienthentilator interface
Psychiatric therapeutics
Renal pathology and therapeutics
Respiratory pathology and therapeutics
Resuscitation therapeutics
Shock and related problems
Thrombosis/hemostasis and therapeutics
Toxicologic therapeutics

Critical Care Pharmacy Practice

236

a specialty unit or a general ICU, the critical care practitioner must focus on a variety of complex patient problems and therapeutic areas (Table I).
Understanding the potential pharmacokinetic changes
experienced by critically ill patients is essential for the
optimal dosing and monitoring of drug therapy in the
critically ill patient.[341 Altered organ blood flow, dysfunction of drug-eliminating organs, and changes in fluid
compartment volumes often dictate the need for individualized approaches to drug d o ~ i n g . [ ~ Pharmacists
~-~~]
are ideally trained to provide comprehensive therapeutic
drug monitoring and optimize expenditures for serum
drug concentration^.'^^]
Universal concern with the comfort of the patient requires knowledge of analgesics and sedatives. Guidelines
have been published to guide the optimal use of these
agents.'391These therapies must be prescribed in a manner
that does not adversely affect the respiratory status of the
patient and, in many cases, is used to facilitate adequate
ventilation of patients with acute lung injury. An understanding of lung injury and mechanical ventilation is essential. Use of pharmacologic agents to induce paralysis
may be an essential part of this care for some patients.[401
Prevention of common adverse events such as stress-related gastrointestinal bleeding and deep venous thrombosis
requires knowledge of the gastrointestinal and coagulation
systems and therapeutics. Nutrition support consultation
is also provided by critical care pharmacists in many settings. Critically ill patients may be highly catabolic and
optimal provision of macro- and micronutrients may enhance their recovery. Proper application of immune-enhancing nutrients has added complexity to the nutritional
support of critically ill patients.
Critically ill patients are at high risk for a variety of
nosocomial infections. Knowledge of infection control
techniques, as well as proper use of prophylactic and
empiric antibiotics, is an important component of critical
care pharmacy practice. Inappropriate antibiotic use can
lead to antimicrobial resistance and outbreaks of nosocomial infection that are difficult to treat with conventional
therapies. Critical care pharmacists work with infection
control staff and infectious disease pharmacists to optimize the use of antimicrobial therapies.
The hemodynamic stability of patients is another universal concern for critical care pharmacists. Patients with
cardiac diseases or postcardiac surgery are obvious candidates for inotropic and vasoactive therapy (vasopressors
and vasodilators). However, patients of all ages with severe injury. sepsis, or the systemic inflammatory response
syndrome require vigorous resuscitation with fluids and
vasoactive agents. Guidelines have been written to guide
the management of these challenging patients.[411Under-

standing the cardiovascular system and therapeutics is

another fundamental portion of a critical care pharmacists' knowledge base. In addition, expertise in the resuscitation of patients experiencing an acute cardiac or respiratory event is an important skill and knowledge set.
Pharmacist knowledge of the current guidelines and participation in cardiopulmonary resuscitation teams is a clinical pharmacy service shown to be associated with reduced hospital
Disease-specific therapies and other fundamental components of the knowledge-base required to practice as a
critical care specialist is outlined in the ASHP requirements for critical care residency training.[441In addition to
direct patient care, the critical care resident should receive
training or experience in drug information and drug policy
development, practice management. and participate in the
management of drug distribution systems in the critical
care setting.
There are currently 21 critical care residencies listed in
the ACCP 2001 Guide to Residencies and Fellowships.
Eight of these residencies are accredited by the ASHP. In
addition, 11 critical care fellowships are available.[451

ClSTS

Critical care pharmacists have demonstrated numerous

contributions to the cost-effective care of ICU patients.
Pharmacist initiated interventions in a 1200-bed teaching
hospital were demonstrated to lower the drug costs by
41% compared with a control group (mean $73.75 vs.
$43.40: p < 0.001).'461Approximately, fifty percent of the
259 patients were in critical care units. The majority
(79%) of the interventions over the 30-day trial period
were aimed at improving the quality of care, whereas the
remaining 2 1% were to provide equivalent care at a lower
cost. There was no impact on length of stay or readmission rates, but there was a trend toward lower hospital
mortality in the intervention group.
Similarly, a multidisciplinary performance improvement team that included a pharmacist established a series
of patient care protocols and tested the impact on the costs
of care and outcome.[301 Protocols were developed that
eliminated many standing orders for laboratory tests,
electrocardiograms, and chest x-ray films. Other protocols
were directed toward the use of sedatives, analgesics,
neuromuscular blocking agents, and ventilator weaning.
The outcome and costs from a baseline evaluation of 72
patients were compared with 85 patients in the follow-up
phase. Application of the guidelines reduced costs for
laboratory tests by 65%, and the number of chest x-rays
were reduced by 56%. The cost of neuromuscular block-

237

Critical Care Pharmacy Practice

ers was reduced by 75%. In addition, the length of ICU

stay and duration of mechanical ventilation were reduced.
There was no change in mortality. If these results can be
extrapolated to a larger population and maintained, significant economic and outcome benefits could be realized.
Another publication from this same group focused on the
impact of guidelines for the use of analgesics, sedatives,
and neuromuscular blocking agents in the same populati~n.~]The pharmacist was involved in protocol
development, education and implementation, and ongoing
intervention when practice did not meet guidelines. A
reduction of direct drug costs, ventilator time, and length
of stay were accomplished by using the protocol. Pharmacists have demonstrated similar results using sedation
protocols elsewhere.[481
Others have shown a positive impact of critical care
pharmacists. A clinical pharmacist working part-time (daily rounds, average 10 hours per week) in a medical ICU
over 8 weeks demonstrated a net benefit of $101 per
day, considering cost avoidance, cost savings, increased
drug costs, and the pharmacists salary.[491Although the
medical ICU was unable to increase staffing levels to
maintain this service, they redistributed pharmacist and
technician workloads to perpetuate the clinical activities.
Similarly, a clinical pharmacist with 50% teaching responsibility was assigned to participate in daily work
rounds with the (medical-surgical patients) critical care
team for 13 weeks.[501 A cost saving using drug costs
only (no personnel costs) was $69.11 per patient day.
Inclusion of personnel costs, for an average of 3 hours
per day, did not negate the cost benefit. High-cost drugs
were targeted, so it may be difficult to maintain this
level of cost savings once the prescribing habits are modified or as protocols are implemented.

ONGOING ~ H A L L E N ~ E S
A focal point for critical care pharmacists and hospitals
with critical care units is a position paper on critical care
pharmacy services jointly developed and published by
ACCP and SCCM.[j This paper identifies and describes
the fundamental, desirable, and optimal activities that
define the scope of practice of the critical care pharmacist
(Table 2 ). Fundamental activities are deemed vital to the
safe provision of pharmaceutical care to the critically ill
patient. The fundamental responsibilities of critical care
pharmacists include a full-time commitment to critical
care patients, evaluation of all drug therapy, identification
of adverse events, individualized drug dosing, provision
of drug information, documentation of activities, and

Table 2 Selected critical care pharmacist activities

Fundamental
Dedicated ICU pharmacist providing pharmaceutical care
Order evaluation and intervention
Adverse drug event and medication error management
and prevention
Documentation of impact
Medication use policy implementation and support
Desirable
Rounding with the critical care team
Medication history review
Resuscitation response
Education of pharmacy students and residents
Implements and evaluates drug therapy protocols or pathways
Participates in clinical research
Optimal
Formal and informal education of the critical care team
Advanced cardiac life support education
Residency or fellowship development
Conducts research and presents and publishes findings
(From Ref. 1511.)

participation in quality improvement activity. At a higher

level of practice, the desirable activities additionally include critical care-specific pharmacotherapeutic services.
Additional desirable activities may include rounding with
a critical care team, review of medication histories, participation in resuscitation events, student and resident
education, protocol development, participation in research, and outcome analysis. At the highest level, the
optimal activities of a critical care pharmacy specialist
include provision of education to families, pharmacists,
and physicians, development of research protocols, new
pharmacy services, and publication of the results of these
programs. A single pharmacist cannot provide all these
services, but rather should function within a team to meet
these goals.
A similar model is used to present the recommended
levels of service and personnel from a pharmacy department and hospital per~pective.[~
Fundamental service
includes the use of patient profiles, provision of ready to
administer medications and parenterals, and adequate
quality improvement programs. Desirable pharmacy services include computerized information management systems and an ICU satellite. Optimal pharmacy department
services include a 24-hour satellite, physician order entry,
and continuous availability of pharmaceutical care services. This document challenges practitioners and institutions to measure their progress and strive for the deli-

238

Critical Care Pharmacy Practice

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20 (1 1); 1400 1406.

t't IARMACY PRACTICE ISSlJ ES

merica
I<ans,,s City, Mmouri, U.S.A.

The object was to identify and describe the scope of

practice that characterizes the critical care pharmacist and
critical care pharmacy services. Specifically the goals
wcrc to define the lcvcl of clinical practice and specialized skills characterizing the critical carc pharmacist as
clinician, educator, researcher, and manager; and to recommend fundamental, desirable, and optimal pharmacy
services and personnel requirements for the provision of
pharmaceutical care to critically ill patients. Hospitals
having comprehensive resources as well as those with
more limited resources were considered.
Consensus of critical care pharmacists rrom institutions of various sizes providing critical care services
within several types 01 pharmacy practice models was
obtained, including community-based and academic practice settings. Existing guidelines and literature describing
pharmacy practice and drug use proccsscs were reviewed
and adapted for the critical care setting.
By combining the strengths and expertise of critical
care pharmacy specialist with existing supporting literature, these recommendations dcfinc thc lcvcl of clinical
practice and specialized skills that characterize the crilical care pharmacist as clinician, educator, researcher, and
administrator. Recommendations include fundamental,
desirable, and optimal pharmacy services as well as personnel rcyuircmcnts or the provision of pharmaceutical
care to critically ill patients.

The discipline of critical care pharmacy practice evolved

since the mid- 1970s to become an essential component of
the multidisciplinary team in thc intcnsivc care unit
(ICU).'"'
In the early 197Os, there were a k w practitioners in critical care who were members of surgical or
From I'harnzucothernpy 2000, 20( I 1): 1400- 1406, with permission of
the American College of Clinical Pharmacy.
(hpyright

240

C 2000 by

lhc Arncrican College of Clinical Pharmacy.

trauma services and cardiac arrest teams. During the next

decade, pharmacy services expanded to various TCU scttings (both adult and pediatric), the operating room, and
the emergency department. In these settings, pharmacists
established clinical practices consisting of therapeutic
drug monitoring, nutrition support, and participation in
patient care rounds. Pharmacists also developed efficient
and safe drug delivery systems with the cvolution of critical care pharmacy satellites and other innovative programs.
In the 19XOs, critical care pharmacists designed specialized training programs and increased participation in
critical care organizations. The number of critical care
residencies and fcllowships doubled between the carly
1980s and the late 1990s. Standards for critical care residency were d e ~ e l o p e d , ' ~and
' directories of residencies
and fellowships were published.'',61 Several professional
pharmacy organizations formed specialty groups consisting of critical care pharmacists. Thcsc include the American College of Clinical Pharmacy (ACCP), American
Society of Health-System Pharmacists, and the Qperatoom Satellite Pharmacy Association. In 1989, the
Clinical Pharmacy and Pharmacology Section was formed
within the Society of Critical Care Medicine, the largest international, multidisciplinary, multispecialty critical care organization. This recognition acknowledged
that pharmacists are necessary and valuablc members of
the physician-led multidisciplinary team.
The Society of Critical Care Medicine Guidelines lor
Critical Care Services and Personnel dccm that pharmacists arc essential for the delivery of quality care to critically ill patients. These guidelines recommend that a
pharmacist monitor drug regimens for dosing, adverse reactions, drug-drug interactions, and cost optimization for
all hospitals providing critical care scrviccs.'" The guidelines also advocate that a specialiad, decentralized pharmacist provide expertise in nutrition support, cardiorcspiratory resuscitation, and clinical research in academic
medical centers providing comprehensive critical care.' I '
Since the early 199Os, clinical pharmacy became increasingly specialized and developed specialty board ceri i f i ~ a t i o n . 'The
~ ' growth of critical care pharmacy practice
paralleled this development. Pharmacists assumed inEncyclo,r~ediaof' Clinicul Phar-mnc-y
D01: 10.108 Iit-ECP 12OOO64O7
Publi4ied 2003 by Mal-ccl Dckkcr, Inc. All rights rcservcd.

241

Critical Care Pharmacy Services (ACCP)

creased responsibility for monitoring patient outcomes as

well as supervising drug distribution service^.'^]
Pharmacists have demonstrated a role in the management of drug costs and reductions in morbidity and mort a l i t ~ . [ ~19]
, ~Clinical
,~pharmacy services such as clinical
research, provision of drug information, drug admission
histories, and participation on a cardiopulmonary resuscitation (CPR) team have been associated with reduced
mortality." 'I Prospective, controlled trials demonstrated
that when pharmacists assume responsibility for pharmacotherapy as part of a multidisciplinary health care team,
significant reductions in adverse drug events (ADEs) and
length of stay are realized."2-'61 Many of these findings
have been documented in specialized critical care populations."4-201 The ACCP estimates that a benefit of
$16.70 is realized for every $1.00 invested in clinical
pharmacy program^."^] A landmark study involving critical care pharmacists confirmed that pharmacist rounding
in the ICU with the multidisciplinary team reduces preventable ADEs and associated costs caused primarily by
prescribing errors."61 Pharmacist intervention during prescribing decreased the rate of preventable ADEs by 66%
from 10.4 to 3.5/1000 patient-days ( p < 0.001). Pharmacist involvement was categorized as drug order clarification (45%), provision of drug information (25%), and recommendations for alternative therapy (12%). Based on an
estimated cost of $4685/preventable ADE, the annualized
financial impact in the unit studied would be $270,000
(1995 dollars).
Despite the growing evidence supporting the critical
care pharmacist's contribution to patient care, many ICUs
have not taken full advantage of this vital resource."'] A
description of pharmacy services and pharmacist activities
in a critical care setting will assist practitioners and administrators in establishing or advancing these specialized
pharmacy services. This article may be used to educate
other health care providers, administrators, and developers of health care policy on the role of pharmacists and
pharmacy services in the care of the critically ill. Furthermore, the application of the elements in this article will
allow researchers to further document the effect of critical
care pharmacy services on improving patient outcomes.

This article identifies and describes the scope of pharmacy practice of the critical care pharmacist and critical
care pharmacy services. Specifically, the aims of the Task
Force on Critical Care Pharmacy Services were:

1. To define the level of clinical practice and specialized skills characterizing the critical care phar-

macist as clinician, educator, researcher, and

manager.
2. To recommend levels of service and personnel
requirements for the provision of pharmaceutical
care to critically ill patients. The levels will be
defined as fundamental, desirable, or optimal.

METHODS
The Task Force on Critical Care Pharmacy Services consisted of members from the Clinical Pharmacy and
Pharmacology Section of the Society of Critical Care
Medicine and the Critical Care Practice and Research
Network of the ACCP. Members of the task force were
from institutions of various sizes and they provide critical
care services within a variety of pharmacy practice models. Practitioners from both community-based and academic practice settings were included.
The formulation of these recommendations, including
discussion and development of consensus, took place between October 1997 and September 1999. Task force
members were charged with developing graded parameters within six domains: clinical activities, drug distribution, education, research, documentation, and administration. This article was organized into pharmacist
activities and pharmacy services. Drafts were reviewed
and evaluated by all members of the task force, and a
consensus was reached. When differences in opinion were
expressed, they were resolved using a modified Delphi
method.[211The document was reviewed externally by
three established leaders in critical care pharmacy and by
18 pharmacy and hospital administrators for appropriateness of categorization of pharmacy activities and services.
The article was further reviewed by select members and
the governance of both the Clinical Pharmacy and Pharmacology Section of the Society of Critical Care Medicine and the Critical Care Practice and Research Network
of the ACCP. Before organizational endorsement, the
article underwent internal review by both the Council of
the Society of Critical Care Medicine and the Board of
Regents of the ACCP.
Existing guidelines and literature for pharmacy practice and drug use processes were reviewed and adapted for
the critical care ~ e t t i n g . [ ~ The
, ~ ~needs
- ~ ~ ]of hospitals with
comprehensive resources as well as those with more limited resources were considered. The task force created
three gradations of pharmacist responsibilities and departmental services as fundamental, desirable, and optimal.
Classification of the elements into each category was the
result of the consensus process. For the purposes of this
article, the following definitions were used. Fundamental
activities are vital to the safe provision of pharmaceutical

242

care to the critically ill patient. Desirable activities include

fundamental activities and critical care-specific pharmacotherapeutic services. Optimal activities encompass the
range of fundamental to desirable services and, additionally, reflect an integrated. specialized, and dedicated model of critical care that aims to optimize pharmacotherapeutic outcomes through the highest level of teaching,
research; and pharmacotherapy practice. Fundamental services should not be interpreted as an acceptable minimum
level of service. Each institution and practitioner continually should strive for the highest level of service possible.
A single pharmacist cannot perform all the fundamental activities on all patients every day. Rather, these
critical care pharmacy activities will require varying levels of involvement from multiple pharmacists and trained
technicians acting as a team, along with support from
pharmacy and hospital administrators, and other personnel. The exact allocation of labor and the pharmacist-topatient ratio will vary by institution and depend on the
level of care, the acuity of patients, and the degree of
specialization of the institution.
The pharmacist, as used herein, refers to the team
of licensed pharmacy practitioners with specialized
training or practice experience focusing on the unique
characteristics and needs of critically ill patients. Although various practice models exist, the pharmacist
practices within the framework of a multidisciplinary
team. In collaboration with other members of the patient
care team. pharmacists share the responsibility for patient
care outcomes, not just by providing basic dispensing
functions and drug information services, but by solving
patient- and drug-related problems and by making decisions regarding drug prescribing, monitoring, and drug
regimen adjustment^."^' The pharmacists practice may
integrate varying elements of patient care, teaching, and
research activities, depending on the nature of the institution and the pharmacists training.
The task force recognizes the varied educational backgrounds of practicing critical care pharmacists. Having
the qualifications and competence necessary to provide
pharmaceutical care in the ICU is essential and may be
achieved by a variety of means including advanced degrees: residencies, fellowships or other specialized practice experiences.
The term pharmacy and hospital services refers to
departmental and institutionaUorganizationa1 components
of the infrastructure that support the pharmacists activities. They consist of systems, operations, and personnel
who facilitate and support the provision of patient care,
teaching, and research to optimize safe and effective
pharmaceutical care of the critically ill.
This article is not intended to be a standard of practice;
however, we envision that it will serve as a guideline for

Critical Care Pharmacy Services (ACCP)

hospitals of varying resources to optimize the delivery of

pharmaceutical care to the critically ill. It is expected that
these recommendations will continue to be reviewed at
intervals of approximately 5 years as critical care pharmacy services, clinical pharmacy, and critical care medicine evolve.

1. The pharmacists time is dedicated to critical care

patients, with few commitments outside the ICU
area.
2. The pharmacist prospectively evaluates all drug
therapy for appropriate indications, dosage, drug
interactions, and drug allergies; monitors the
patients pharmacotherapeutic regimen for effectiveness and ADEs; and intervenes as needed.
3. In conjunction with the clinical dietitian, the
pharmacist evaluates all orders for parenteral nutrition and recommends modifications as indicated to optimize the nutritional regimen.
4. The pharmacist identifies ADEs and assists in
their management and prevention, and develops
process improvements to reduce drug errors and
preventable ADEs.
5 . The pharmacist uses the medical record as one
means to communicate with other health care
professionals and to document specific pharmacotherapeutic recommendations.
6. The pharmacist provides pharmacokinetic monitoring when a targeted dmg is prescribed.
7 . The pharmacist provides drug information and
intravenous compatibility information to the ICU
team and uses the regional poison information
center when indicated.
8. The pharmacist maintains current tertiary drug
references.
9. The pharmacist provides drug therapy-related
education to ICU team members.
10. The pharmacist participates in reporting ADEs to
institutional committees and to the Food and
Drug Administrations MedWatch program.
11. The pharmacist documents clinical activities that
include, but are not limited to, disease state management, general pharmacotherapeutic monitoring, pharmacokinetic monitoring, ADEs, education, and other patient care activities.
12. The pharmacist acts as a liaison between pharmacy, nursing, and the medical staff to educate health professionals regarding current drug-

243

Critical Care Pharmacy Services (ACCP)

13.

14.

15.

16.

17.

18.

related procedures. policies, guidelines, and

pathways.
The pharmacist contributes to the hospital newsletters and drug monographs on issues related to
drug use in the ICU.
The pharmacist implements and maintains departmental policies and procedures related to safe
and effective use of drugs in the ICU.
The pharmacist collaborates with nursing, medical staff, and hospital administration to prepare
the ICU for the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO)
survey and responds to any deficiencies identified.
The pharmacist provides consultation to hospital
committees, such as Pharmacy and Therapeutics,
when critical care pharmacotherapy issues are
discussed.
The pharmacist identifies how drug costs may be
minimized through appropriate use of drugs in
the ICU and through implementation of costcontainment measures.
The pharmacist participates in quality assurance
programs to enhance pharmaceutical care.

7 . The pharmacist participates in training pharmacy

students, residents, and fellows through experiential critical care rotations, where applicable.
8. The pharmacist coordinates the development and
implementation of drug therapy protocols andlor
critical care pathways to maximize benefits of
drug therapy.
9. The pharmacist uses a documentation program
that attaches both a clinical significance and an
economic value to clinical interventions.
10. The pharmacist is actively involved in critical
care pharmacotherapy research by assisting in the
screening and enrollment of patients and by
serving as a study coordinator or contact person,
where applicable.
11. The pharmacist participates in research design
and data analysis, where applicable.
12. The pharmacist contributes to the pharmacy and
medical literature, e.g., case reports, letters to
the editor, and therapeutic, pharmacokinetic, and
pharmacoeconomic reports.
13. The pharmacist is involved in nonpatient care
activities including multidisciplinary committees
and educational in-services.

Desirable Activities
Optimal Activities
1. The pharmacist regularly makes rounds as a
member of the multidisciplinary critical care team
(if available) to provide pharmacotherapeutic
management for all ICU patients.
2. The pharmacist maintains knowledge of current
primary references pertinent to critical care pharmacotherapy.
3. The pharmacist reviews a patients drug history
to determine which maintenance drugs should be
continued during the acute illness.
a. The pharmacist clarifies previously effective
dosages and dosage regimens.
b. For all suspected drug-related ICU admissions, the pharmacist assesses the patient
drug history for causality and documents in
the medical record any findings that will
impact patient management.
In
collaboration
with the clinical dietitian, the
4.
pharmacist provides formal nutrition consultation
on request and responds within 24 hours.
5 . The advanced cardiac life support-certified (or
pediatric advanced life support-certified) pharmacist responds to all resuscitation events in the
hospital 7 dayslweek, 24 hourslday.
6. The pharmacist provides didactic lectures to
health professional students in critical care pharmacology and therapeutics, where applicable.

1. The pharmacist assists physicians in discussions

2.

3.

4.

5.

6.

7.

8.

with patients andlor family members to help

make informed decisions regarding treatment
options.
The pharmacist provides formal accredited educational sessions, such as medical grand rounds
or intensive care rounds, for medical staff, students, and residents.
The pharmacist participates in teaching advanced
cardiac life support.
The pharmacist develops residencies and/or
fellowships in critical care pharmacy practice.
The pharmacist develops and implements pharmacist and pharmacy technician training programs for personnel working in the ICU.
The pharmacist identifies and educates lay
groups and medical personnel in the community
about the role of pharmacists as part of the multidisciplinary health care team in the ICU.
The pharmacist independently investigates or
collaborates with other critical care practitioners
to evaluate the impact of guidelines and/or protocols used in the ICU for drug administration
and management of common disease states.
The pharmacist uses pharmacoeconomic analyses
to prospectively evaluate existing or new phar-

244

Critical Care Pharmacy Services (ACCP)

9.
10.
11.

12.

macy services and the place of new drugs in critical care pharmacotherapy.
The pharmacist is proactive in designing, prioritizing, and promoting new pharmacy programs
and services.
The pharmacist secures funds for conducting
research.
The pharmacist reports results of clinical research and pharmacoeconomic analyses to the
pharmacy and medical community at regional
and national meetings.
The pharmacist publishes in peer-reviewed pharmacy and medical literature as a result of any of
the following activities:
a. Clinical research or other original research
that qualitatively and quantitatively evaluates drug therapy and the provision of pharmacy services.
b. Investigator-initiated grants and contracts.
c. Pharmacoeconomic and outcomes research.

VICE

1. Drug use systems can do the following:

a. Create and maintain patient drug profiles.
b. Interface with patient laboratory data.
c. Alert users to drug allergies.
d. Alert users to maximum dosage limits.
e. Alert users to drug-drug and drug-foodlnutrient interactions.
2. If manual drug administration records are the
only available drug administration document,
quality assurance systems are in place to verify
the accuracy of this process.
3. A ready to administer (unit-dose) drug distribution system is available in the ICU with no
more than a 24-hour supply for each patient.
4. Large- and small-volume parenteral products are
prepared in the pharmacy and delivered at regularly scheduled times to the patient care area
7 dayslweek.
5 . Pharmacy space and facilities in the ICU are assessed routinely to determine whether efficiency
can be improved, where applicable.
6. Procurement, storage, inventory, and distribution
of investigational drugs, where applicable, are
under the supervision of a pharmacist.
7
The pharmacy department is represented on the
Institutional Review Board andlor Scientific Review Board, as applicable.

1. The hospital information management system is

computerized, can comply with the requirements
listed for drug use processes (see Fundamental
Services, Item l), and can do the following:
a. Alert users to disease state-drug interactions.
b. Provide intravenous admixture information
(e.g., compatibility, stability, preparation).
c. Provide online drug and poison information.
d. Document clinical pharmacy patient care interventions.
2. Computerized drug administration records are
generated. Manual records are used only in
emergencies.
3. An ICU satellite pharmacy with unit-dose drug
distribution and intravenous admixture capabilities
is open a minimum of 40 hourslweek.

1. The computerized hospital information management system serving the ICU has the following
additional capabilities:
a. Direct physician drug order entry at patient
bedside.
b. Interface with bedside clinical information
system.
2. An ICU satellite pharmacy with unit-dose drug distribution and intravenous admixture capabilities is
open 24 hourslday, 7 dayslweek.
3. Pharmacotherapeutic, pharmacokinetic, and nutrition consultation are available 24 hourslday,
7 dayslweek.

The task force acknowledges the following individuals for

their review of this manuscript: Bradley A. Boucher,
Pharm.D., FCCP, FCCM, BCPS, University of Tennessee, Memphis, TN; Joseph F. Dasta, M.S., FCCP, FCCM,
Ohio State University, Columbus, OH; and Barbara J.
Zarowitz, Pharm.D., FCCP, FCCM, BCPS, Henry Ford
Health System, Bingham Farms, MI.
This position paper was developed by a task force of
the Clinical Pharmacy and Pharmacology Section of the
Society of Critical Care Medicine and the Critical Care
Practice and Research Network of the American College
of Clinical Pharmacy. It was approved by the Council of
the Society of Critical Care Medicine on February 10,
2000, and the Board of Regents of the American College
of Clinical Pharmacy on October 5 , 1999.

245

Critical Care Pharmacy Services (ACCP)

Task force members were Maria I. Rudis, Pharm.D.,

University of Southern California, LOS Angeles, CA
(Chair); Henry Cohen, Pharm.D., Long Island University,
New York, NY; Bradley E. Cooper, Pharm.D., Hamot
Medical Center, Erie, PA; Luis S. Gonzalez, 111,
Pharm.D., Conemaugh Medical Center, Erie, PA; Erkan
Hassan, Pharm.D., FCCM, University of Maryland,
Baltimore, MD; Christian Klem, Pharm.D., Tampa
General Healthcare, Tampa, EL; Vanessa L. Kluth-Land,
Pharm.D., SmithKline Beecham Pharmaceuticals, HQW
ton, TX; Katherine M. Kramer, Pharm.D., University of
New Mexico, Las Cruces, NM; Angela M. Swerlein,
Pharm.D., GrantRiverside Methodist Hospitals, Columbus, OH; Julie Ann Whippel, Pharm.D., Waukesha
Memorial Hospital, Waukesha WI. At the time of manuscript preparation, Dr. Kluth-Land was at Hermann HQSpital, Houston, TX.

1. American College of Critical Care Medicine and the

Society of Critical Care Medicine. Critical care services
and personnel: Recommendations based on a system of
categorization into two levels of care. Crit. Care Med.
1999. 27, 422-426.
2. Dasta, J.F.; Jacobi, J. The critical care pharmacist: What
you get is more than what you see. Crit. Care Med. 1994,
22, 906-909.
3. Dasta, J.F.; Jacobi, J.; Armstrong, D.K. Role of the
Pharmacist in Caring for the Critically I11 Patient. In The
Pharmacologic Approach to the Critically Ill Patient, 3rd
Ed.; Chernow, B., Ed.; Williams & Wilkins: Baltimore,
1994; 156-166.
4. American Society of Hospital Pharmacists. Supplemental
standard and learning objectives for residency training in
critical care pharmacy practice. Am. J. Hosp. Pharm. 1990,
47, 609-612.
5. Society of Critical Care Medicine. Directory of Critical
Care Residencies and Fellowships. In Clinical Pharmacy
and Pharmacology Section; Society of Critical Care
Medicine: Anaheim, California, 2000.
6. American College of Clinical Pharmacy. Directov of
Residencies and Fellowships; American College of Clinical Pharmacy: Kansas City, Missouri, 2000.
7. American College of Clinical Pharmacy Practice Affairs
Committee. Practice guidelines for pharmacotherapy specialists. Pharmacotherapy 200
8. Hatoum, H.T.; Hutchinson, R.A.; Witte, K.W., et al.
Evaluation of the contribution of clinical pharmacists:
Inpatient care and cost reduction. Drug Intell. Clin. Pharm.
1988, 22, 252-259.

9. Bond, C.A.; Raehl, C.L.; Pittele, M.E., et al. Health care

professional staffing, hospital characteristics, and hospital
mortality rates. Pharmacotherapy 1999, 19, 130- 138.
10. Chuang, L.C.; Suttan, J.D.; Henderson, J.P. Impact of the
clinical pharmacist on cost saving and cost avoidance in
drug therapy in an intensive care unit. Hosp. Pharm. 1994,
29, 215-221.
11. Bond, C.A.; Raehl, C.L.; Franke, T. Clinical pharmacy
services and hospital mortality rates. Pharmacotherapy
1999, 19, 556-564.
12. Bjornson, D.C.; Hiner, W.O.; Potyk, R.P., et al. Effect of
pharmacists on health care outcomes in hospitalized patients. Am. J. Hosp. Pharm. 1993. 50, 1875-1884.
13. Boyko, W.L.; Yurkowski, P.J.; Ivey, M.F., et al. Pharmacist influence on economic and morbidity outcomes in a
tertiary care teaching hospital. Am. J. Health-Syst. Pharm.
1997, 54, 1591-1595.
14. Kelly, W.N.; Meyer, J.D.; Flatley, C.J. Cost analysis of a
satellite pharmacy. Am. J. Hosp. Pharm. 1986. 43, 19271930.
15. Smythe, M.A.; Shah, P.P.: Spiteri, T.L.. et al. Pharmaceutical care in medical progressive care patients. Ann. Pharmacother. 1998, 32, 294-299.
16. Leape, L.L.; Cullen, D.J.; Clapp, M.D., et al. Pharmacist
participation on physician rounds and adverse drug events
in the intensive care unit. JAMA 1999. 282, 267-270.
17. Schumock, G.T.; Meek, P.D.; Ploetz, P.A., et al. Economic
evaluations of clinical pharmacy services-1988- 1995.
Pharmacotherapy 1996, 16, 1188- 1208.
18. Matuszewski, K.A.; Vlasses, P.H. Survey results from
academic health center intensive care units: Considerations
for departments of pharmacy. Clin. Ther. 1995, 17. 517525.
19. Montazeri, M.; Cook, D.J. Impact of a clinical pharmacist
in a multidisciplinary intensive care unit. Crit. Care Med.
1994, 22, 1044-1048.
20. Miyagawa, C.I.; Rivera, J.O. Effect of pharmacist interventions on drug therapy costs in a surgical intensive care
unit. Am. J. Hosp. Pharm. 1986, 43, 3008-3113.
21. Dalkey, N.C. The Delphi Method: An Experimental Study
of Group Opinion; Rand Corporation: Santa Monica,
California, 1969.
22. Joint Commission on the Accreditation of Healthcare
Organizations. Standards for Hospitals; JCAHO: Chicago,
Illinois, 1998.
23. American Pharmaceutical Association. Pharmacy Practice
Activity Classification; APhA: Washington, DC, 1998.
24. Anonymous. Over-reliance on pharmacy computer systems may place patients at great risk. ISMP Med. Saf.
Alert. 1999, 4. 1, Available from: http:/,www.ismp.org/
MSArticles/Computer.html.
25 American College of Clinical Pharmacy. Collaborative
drug therapy management by pharmacists. Pharmacotherapy 1997, 17, 1050-1061.
I

PHARMACY PRACTICE ISSUES

avi
Universily of Iowa, Iowa City, Iowa, U.S.A

The cytochrome P450 (CUP) is a major hemo (ironcontaining) protein family that catalyzes drug and
xenobiotic metabolism. It is present in the microsomes
(tiny ineinbrane vesicles of endoplasmic reticulum) of
many different cells in the body, but it is at highest
concentration in liver."' There are two types of microsomal en7ymes in the body: those catalyzing mainly
oxidations (termed the phase I enzymes) and those catalyzing conjugations (termed the phase I1 enzymes).r21
The CYP is the most important enzyme system catalyzing
phase 1 metabolism reactions such as oxidation, reduction,
and hydrolysis. It generally serves as a detoxification
mechanism for lipophilic drugs and xcnobiotics by converting them to more water-soluble compounds."] However, this enzyme system occasionally transforms nontoxic chemicals or drugs into toxic reactive intermediates,
or procarcinogcns into carcinogens. In addition, it converts hormones and steroids into more active forms.

In the late 1950s, it was discovered that when rat liver

microsomes were treated in a certain condition, a strong
absorption band occurred at approximately 450 nm
wavelength in the spectrophotomcter, which was very
unusual for the pigments.'" The red pigment responsible
for this phenomenon was called P (for pigment) 450. It
was later named "cytochrome P450" because it was
believed to be similar to mitochondria1 c y t o ~ h r o m e s . ' ~ ~
At first, it was believed that the P450 was a single
protein, but soon it became apparent that it was not a
single protein but comprised a number of direrent
proteins. Each human CYP protein identified appears
to be the expression of an unique gene. There are more
than 1000 unique genes for CUP identified among prokaryotes and eukaryotes to date.'" There are significantly

246

common amino acid sequences among all CYPs in a

few regions or the proteins, suggesting a common ancestry. For this reason, the CYP is referred to as a supergene famiiy.L6.7i
Accordingly, a recommended nomenclature system has
been devised based on the evolutionary relations of thcsc
enzymes.17' According to this system, the deduced amino
acid sequences from the genes arc compared and divided
into lamilies, which comprise those CYPs that share at
least 40% identity and designated by Arabic number after
CYP (i.c., CYPI, 2, 3, etc.). These families are divided
further into subramilies, which comprise those rorms that
are at least 55% rclatcd by their deduced amino acid
sequences, and are designated by a capital letter after the
Arabic number (i.e., C Y P l A , CYP2D, etc.). Each
individual enzyme is designated by Arabic number after
subfamily ( k . , CUP1 A2, CYP3A4).

There are numerous CYPs identified in humans, animals,

and plants, but currently three P450 gene families, including CYP1, CYP2, and CYP3, arc responsible for most
of human drug metabolism.'x1 These three CYP gene
families, their subfamilies, and their major substrates arc
illustrated in Table 1 . In drug metabolism, CYPlA2,
CYP2C9, CUP2C19, CYP2D6, and CYP3A4 are important. Especially, approximately 75% of all therapeutic
agents are metabolixd by CYP2D6 and CYP3A4

It is well known that each patient may respond variably

even when each patient receives the same dose of the

Etzcjcloperlia (d Clinical Phnriiiucy

DOT: 10.1081E-ECP I20006216
Copyright C 2003 by Marcel Dckker, Inc. All rights rcierved.

Cytochrome P450

247

Table 1 Major CYP enzymes, their substrates, inducers, inhibitors, and phenotype markers
Enzyme

Representative
substrates

CYPlA2

Caffeine
Theophy lline

CYP2C9

Warfarin
Tobutamide
Mephenytoin
Omeprazole
Metopronolol
Imipramine

CYP2C 19
CYP2D6

CYP2E1
CYP3A314

CYP3A5

Encainide
Ethanol
Acetaminophen
Cyclosporine
Verapamil
Nifedipine
blockers
Cyclosporine

Inhibitor

Known inducer

Polymorphism

Noninvasive test marker

Tobacco
Charcoalbroiled meat
Barbiturates
Rifampin
Barbiturates
Rifampin
Barbiturates
Rifampin in
EMS only

Fluvoxamine

(Yes)"

Caffeine

Sulfaphenazole

(Yes)"

Tobutamide

Yes

(S)-Mephenytoin

Quinidine

Yes

Dextromethorphan

Ethanol
Isoniazid
Phen ytoin
Rifampin
Barbiturates

Disulfiram

(Yes)"

Debrosoquine
Chlorzoxazone

Erythromycin
Verapamil
Ketoconazole

(Yes)"

Erythromc yin

Barbiturates
Rifampin

Grapefruit juice
Ketoconazole
Erythromycin

Midazolam

Yes

Erythromycin

"There are no conclusive evidences between genotype and phenotype, although some phenotype or genotype differences are detected in the population.

same medication. Many factors involve this inter- and

intrapatient variability of drug response. The recommended dose of each therapeutic agent is determined
based on clinical study results from a small number of
patients who meet a narrowly defined criteria. However,
the optimal daily dose in clinical practice can vary widely
among patients because of factors such as age, size of the
patient, gender, ethnicity, concurrent drug therapy, food
intake, and the patient's own disease conditions (i.e., renal
function o r liver function)."'] It should be noticed that
each individual patient has his or her own optimal dose of
drug therapy in a specific clinical condition. Because the
CYP is an important enzyme system for various drug
classes, large differences in the activities of the CYP
among individuals explain some of this wide variability in
the dosing requirements of various drugs."']
Most drugs are metabolized by multiple metabolic
pathways, which is necessary because this may protect the
body from the toxic effects of drugs in case one metabolic
pathway is shut down. However, in certain cases, single
enzyme activity largely determines drug response. For
example, the therapeutic effect of the drug may be
correlated with the blood levels of the parent drug, and
this may depend largely on the rate of metabolism of
the drug catalyzed by a single CYP. Although it is not
always true, there are now at least several important
examples in which the relation between drug dose, blood

levels, and therapeutic response in an individual patient is

largely determined by the catalytic activity of single
enzyme, CYP2D6. For example, patients with the poor
metabolizer phenotype for CYP2D6 demonstrate significantly high area under the plasma concentration time
curve for metoprolol, compared with extensive metabolizers of CYP2D6.[12] As a result, poor metabolizers
generally attain therapeutic effects from these drugs at
significantly reduced daily doses. If the same dose as a
rapid metabolizer is given, the patients will develop severe toxicity.
The activity of CYP3A varies at least 10-fold among
patients, and the activity level in a given patient appears
to be related to the dosing requirements of a certain
substrate metabolized by CYP3A.['32'41It has been shown
that the liver activity of CYP3A largely predicts blood
levels of cyclosporine in patients receiving the drug for
treatment of psoriasis;['31 that is, patients with higher
CYP3A activity have lower blood levels of cyclosporine
at any given daily dose of the d r ~ g . " ~ . ' ~ ]
There are significant differences in CYP enzyme
activities in the general population. which are mainly
determined by genetics, although some environmental
factors such as enzyme inducers or inhibitors are
involved. One of the best known CYP enzyme inducer
is cigarette smoking, which generally induces CYPlA2
and other CYP enzyme^.['^,^^] In a certain population,

248

Cytochrome P450

there is genetically a lack of CYP genes (i.e., CYP2C19,

CYP2D6), and these populations may develop significant
toxicity if the standard dose of a drug with a narrow
therapeutic index is given.

YP

The CYP is present not only in the liver, but also in the
intestine. It appears that the CYP is located mainly at the
apex of the mature enterocytes, lying in a band just below
the microvillous border.['s1 In humans, the major
enterocyte CYP appears to be the CYP3A4, which
accounts for more than 70% of CYP activity in the
intestine. Interestingly, CYP3A4 is located along with Pglycoprotein, a cell membrane efflux pump."'] This may
indicate that CYP3A4 along with P-glycoprotein are
intended to prevent the environmental toxins, or xenobiotics such as drugs, from entering the body. The
intestinal metabolism of many lipophilic drugs metabolized by CYP3A4 is estimated to be as much as one-half
of the administered dose.[201 Previously, many CYP
inhibitors were thought to act only on liver CYP enzymes,
but it was found that they affect on both liver and
intestinal CYP.['93201
For example, ketoconazole, which is
a potent inhibitor of CYP3A4, increases area under the
curve of cyclosporine not only by inhibiting hepatic
CYP3A4, resulting in reducing metabolism of cyclosporine, but also inhibiting intestinal CYP3A4, subsequently
increasing bioavailability of cyclosporine.[211Some food
components such as grapefruit juice inhibit CYP3A in the
intestine and, when oral felodipine is given with
grapefruit juice, its AUC and Cmax are increased by
250% and 150%,[221respectively. However, when intravenous felodipine is given with grapefruit juice, there is
no significant difference.[221

Drug interactions constitute a major problem in chronic

multiple drug therapy.[231Although interactions affecting
the pharmacodynamics of a drug can be reasonably predicted (i.e., additive effect or synergistic effect), those
affecting its pharmacokinetics are difficult to predict.
These might result from various contributions involving
absorption, transportation, distribution, metabolism, and
excretion.[231Among these, metabolism in liver as well as
intestine appears to represent the major source of drugdrug interactions. Because CYP enzymes are known to be

induced or inhibited by, and involved in the oxidation of,

a number of currently used drugs, they are likely to be
responsible for numerous drug interactions in humans.12]
Because CYP3A4 metabolizes more than 50% of all
therapeutic agents, its inhibitors and inducers have
significant impact. Clinically important CYP3A4 inhibitors include ketoconazole, itraconazole, erythromycin,
clarithromycin, nefazodone, ritonavir, and grapefruit
jUiCe.[23241
Torsades de pointes, a life-threatening ventricular
arrhythmia associated with QT prolongation, can occur
when these inhibitors are coadministered with terfenadine, astemizole, or cisapride because they inhibit these
agents from converting the parent compound into
nontoxic, pharmacologically active metabolite^.[^^-^^]
As a result, the proarrhythmic parent compound accumulates in the body, which causes toxic effects.
Because of this serious drug interactions, these drugs
have to be withdrawn from the market. Cyclosporine, an
important immunosuppressant, has clinically been
shown to be involved in multiple drug interactions.[231
Because cyclosporine is extensively metabolized in
human liver and enterocytes by CYP3A4, any inducer
of CYP3A4 (e.g., ripampin) should cause a decrease in
cyclosporine levels, whereas any substrate or inhibitor
(e.g., ketoconazole) of this CYP should elicit the
opposite effect. Indeed, this has been clearly demonstrated clinically[2s1 as well as in an experimental
model. [291
Some drugs with multiple metabolic pathways are
affected by many different inhibitors. For example, codeine is metabolized by CYP2D6 and CYP3A4, which act
on different sites of action.[301 The 0-demethylation of
codeine is catalyzed by CYP2D6 and N-demethylation is
catalyzed by CYP3A4.[311The substrates of CYP2D6,
such as thioridazine, amitriptyline, and metoprolol inhibit
the 0-demethylation of codeine preferentially,[301whereas
substrates of CYP3A4, such as ketoconazole, are strong
inhibitors of the N-demethylation of codeine.[311
Not all predicted drug interactions are expected to
be clinically significant. For example, nifedipine and
cyclosporine are both CYP3A4 substrates, but there is
no clinically important drug interaction noticed.[231 To
predict the drug interaction, several parameters are
expected to be important. These include notably:[321
1) relative affinity of CYP enzyme on both drugs (km);
2) dose and local concentration of each drug either in
enterocytes or hepatocytes; 3) duration of concurrent
therapy; and 4) CYP enzyme in the liver or intestine
of the patient. The level of CYP3A is highly variable
in each individual. It is possible that, in one patient
with a low CYP3A level, all the cytochrome would

Cytochrome P450

249

be saturated by the coadministered drugs, but not in

another with higher CYP3A level: the consequence is
that the interaction should occur in the former but not
the latter.

activity.[411In the near future, genotyping information

regarding individual CYP will be readily available,
which may better explain individual variability of drug
pharmacokinetics and pharmacodynamics.

It would be great to measure the activity of individual

CYP enzymes and predict drug response or drug interaction in individual patients because of the CYP
enzymes involved in the metabolism of various therapeutic agents.[331A reliable in vivo probe for phenotyping CYP3A4 would make it possible to identify
individuals at greatest risk of toxicity due to high blood
levels and inefficacy due to subtherapeutic blood levels,
and to detect potentially dangerous drug-drug interaction~.[~~]
CYP3A is the predominant drug-metabolizing enzyme
in humans. Thus, there have been considerable efforts
to develop a simple, safe, and reliable phenotyping
procedure for CYP3A activity; however, these efforts
are largely suboptimal.[331Among candidate probes, two
procedures have shown clinical utility, intravenous midazolam clearance[351 and the erythromycin breath test
(ERBT).[363371
There is strong evidence that the clearance
of midazolam provides an estimate of liver CYP3A act i ~ i t y . [ ~However,
*]
it has a potent sedative effect, and the
multiple blood sampling required for pharmacokinetic
evaluation makes it inappropriate for widespread use in
an outpatient setting.
and has
The ERBT has been most widely
a significant correlation with the pharmacokinetics of the
CYP3A substrate, c y ~ l o s p o r i n e . [ The
' ~ ~ ERBT correlates
with trough blood concentration of cyclosporine in
patients with p s ~ r i a s i s " ~and
] with the oral clearance of
cyclosporine in transplant recipient^."^^ However, as a
probe for CYP3A activity, the ERBT has significant
limitations. Not only does it require intravenous access,
which may exclude the fraction of gastrointestinal
metabolism by CYP3A, but it also requires the administration of a radioactive substance, a potential safety
concern.[331In addition. ERBT fails to show a significant
correlation with other known CYP3A4 substrates, such as
a l f e n t a ~ ~ i l 'or
~ ~dapsone
]
Other markers
such as dapsone, or the 6p-hydroxy cortisol urine test,
have been tried with variable results.[4o1Dextromethorphan shows some promise as a probe simultaneously
measuring both CYP2D6 and CYP3A4 acitivity, but its
urine metabolic ratios failed to predict CYP3A4

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3. Guengerich, F.P. Enzymatic oxidation of xenobiotic
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5. Harding, B.W.; Wong, S.H.; Nelson, D.H. Carbon monoxide-combining substances in rat adrenal. Biochem.
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6. Nebert, D.W.: Carvan, M.J. Ecogenetics: From ecology to
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7. Nebert, D.W.; Nelson, D.R.; Coon, M.J.; Estabrook,
R.W.: Feyerseisen, R.; Fuji-Kuriyama, Y.: Gonzalez,
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Loper, J.C.: Sata, R.: Waterman, M.R.: Waxman, D.J.
The P450 superfamily: Update on new sequences, gene
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8. Wrighton, S.A.; Stevens, J. The human hepatic cytochromes P450 involved in drug metabolism. Crit. Rev.
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9. Benet, L.Z.; Kroetz, D.L.; Sheiner, L.B. The Dynamic of
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9th Ed.; Hardman, J.G., Limbird, L.E., Molinoff, P.B.,
Ruddon. R.W., Eds.; McGraw-Hill. 1996: 3-27.
10. Lindholm, A. Factors influencing the pharmacokinetics
of cyclosporine in man. Ther. Drug Monit. 1991, 13,
465 -477.
11. S koda, R.C. ; Gonzalez, F.J. ; Demierre, A,;Meyer, U. A.
Two mutant alleles of the human cytochrome P-450dbl
gene (P450C2D1) associated with genetically deficient
metabolism of debrisoquine and other drugs. Proc. Natl.
Acad. Sci. 1988, 85, 5240-5243.
12. Lennard, M.S.; Silas, J.H.; Freestone, S.; Trevethick, J.
Defective metabolism of metoprolol in poor hydroxylators of debrisoquine. Br. J. Clin. Pharmacol. 1982, 14,
301-303.
13. Kahan, B.D. Cyclosporine. N. Engl. J. Med. 1989, 321,
1725- 1738.
14. Watkins, P.B.; Hamilton, T.A.; Annesley, T.M.; Ellis,
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Pharmacol. Ther. 1990, 48, 120-129.
Turgeon, D.K.; Normolle, D.P.; Leichtman, A.B.; Annesley, T.M.; Smith, D.E.; Watkins, P.B. Erythromycin breath
test predicts oral clearance of cyclosporine in kidney
transplant recipients. Clin. Pharmacol. Ther. 1992, 52,
471 -478.
Nakachi, K.; Imai, K.; Hayashi, S.-I.; Watanabe, J.;
Kawajiri, K. Genetic susceptibility to squamous cell carcinoma of the lung in relation to cigarette dose. Cancer
Res. 1991, 51, 5177-5180.
Nebert, D.W. Role of genetics and drug metabolism in
human cancer risk. Mutat. Res. 1991, 247, 267-281.
Kolars, J.C.; Schmiedlin-Ren, P.: Dobbins, W.O.; Schuetz,
J.: Wrighton, S.A.; Watkins, P.B. Heterogeneity of
cytochrome P450IIIA expression in rat gut epithelia.
Gastroenterology 1991, 102. 1186- 1198.
Wacher, V.J.; Wu, C.-Y.; Benet, L.Z. Overlapping
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P450 3A and P-glycoprotein: Implications for drug
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Wu, C.-Y.; Benet, L.Z.; Hebert, M.F.; Gupta, S.K.;
Rowland, M.; Gomez, D.Y.; Wacher, V.J. Differentiation
of absorption and first-pass gut and hepatic metabolism in
humans: Studies with cyclosporine. Clin. Pharmacol. Ther.
1995, 58, 492-497.
Gomez, D.Y.; Wacher, V.J.; Tomlanovich, S.J.; Hebert,
M.F.; Benet, L.Z. The effects of ketoconazole on the intestinal metabolism and bioavailability of cyclosporine.
Clin. Pharmacol. Ther. 1995, 58. 15-19.
Baily, D.G.; Arnold, M.O.; Munoz, C.; Spence, J.D.
Grapefruit juice-felodipine interaction: Mechanism, predictability, and effect of naringin. Clin. Pharmacol. Ther.
1993, 53, 637-642.
Yee, G.C.: McGuire, T.R. Pharmacokinetc drug interactions with cyclosporine. Clin. Pharmacokinet. 1990, 19,
319-332 and 400-415.
Ku, Y.; Min, D.I.; Flanigan, M. Effect of grapefruit juice
on microemulsion cyclosporine and its metabolites, M1
and M17 pharmacokinetics in healthy volunteers. J. Clin.
Pharmacol. 1998, 38, 959-965.
Honig, P.K.; Worthan, D.C.; Zamani, K.; Conner, D.P.;
Mullin, J.C.; Cantilena, L.R. Terfenadine-ketoconazole
interaction: Pharmacokinetic and electrocardiographic
consequences. JAMA, J. Am. Med. Assoc. 1993, 269,
1513-1518.
Zechnich, A.D.; Hedges, J.R.; Eiselt-Proteau, D.; Haxby,
D. Possible interactions with terfenadine or astemizole.
West. J. Med. 1994, 160 (4). 321-325.
Chan-Tompkins, N.H.; Babinchak, T.J. Cardiac arrhythmias associated with coadministration of azole compounds
and cisapride. Clin. Infect. Dis. 1997, 24 (6), 1285-1313.
Jensen, C.W.B.; Flechner, S.M.; Van Buren, C.T.; Frazier,
O.H.; Cooley, D.A.; Lorber, M.I.; Kahan, B.D. Exacerbation of cyclosporine toxicity by concomitant administration of erythromycin. Transplantation 1987, 43 (2),
263-269.

29. Wang, R.W.; Newton, D.J.; Liu, N.; Athns, W.M.; Lu,
A.Y.H. Human cytochrome P-450 3A4: in vitro drug-drug
interaction patterns are substrate-dependent. Drug Metab.
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debrisoquine 4-hydroxylation of debrisoquine. Biochem.
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Alhava, E.; Pelkonen, 0.;Lang, M.: Pasanen, M. Codeine
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Eur. J. Pharmacol., Environ. Toxicol. Pharmacol. Sect.
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32. De Waziers, I.; Cugnenc, P.H.; Yang, C.S.; Leroux, J.P.;
Beaune, P.H. Cytochrome P450 isoenzymes epoxide
hydrolase and glutathione transferases in rat and human
heaptic and extrahepatic tissues. J. Pharmacol. Exp. Ther.
1990, 253, 387-394.
33. Watkins, P.B. Noninvasive tests of CYP3A enzymes.
Pharmacogenetics 1994, 4, 171- 184.
34. Lown, K.; Kolars, J.; Turgeon, K.; Merion, R.; Writhton,
S.A.; Watkins, P.B. The erythromycin breath test selectively measures P450IIIA in patients with severe liver
disease. Clin. Pharmacol. Ther. 1992, 51; 229-238.
35. Thummel, K.E.; Shen, D.D.; Podoll, T.D.; Kunze, K.L.;
Trager, W.F.; Hartwell, P.S.; Raisys, V.A.; Marsh, C.L.;
McVicar, J.P.; Barr, D.M. Use of midazolam as a human
cytochrome P450 3A probe: I. In vitro-in vivo correlations in liver transplant patients. J. Pharmacol. Ther. 1994,
271 (l), 549-556.
36. Lown, K.; Thummel, K.E.; Benedict, P.E.; Shen, D.D.;
Turgeon, D.K.: Berent, S.; Watkins, P.B. The erythromycin breath test predicts the clearance of midazolam. Clin.
Pharmacol. Ther. 1995, 57, 16-24.
37. Watkins, P.B. Erythromycin breath test and clinical
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38. Kronbach, T.; Mathys, D.; Umeno, M.; Gonzalez, F.J.;
Meyer, U.A. Oxidation of midazolam and tnazolam by
human liver cytochrome P450IIIA4. Mol. Pharmacol.
1989, 36, 89-96.
39. Krivoruk, Y.; Kinirons, M.T.; Wood, A.J.; Wood, M.
Metabolism of cytochrome P4503A substrates in vivo
administered by the same route: Lack of correlation
between alfentanil clearance and erythromycin breath test.
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A.T.; Joellenbeck, L.; Groopman, J.D.; Wilkinson, G.R.;
Wood, A.J. Absence of correlations among three putative
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621 -629.
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urine metabolic ratio of dextromethorphan and 3-methoxymorphinan as a probe for CYP3A415 activity and
prediction of cyclosporine clearance in healthy volunteers.
Phannacotherapy 1999, 19, 753-759.

PROFESSIONAL ORGANIZATIONS

eSSe
Niantic, Connecticut, U.S.A.

The Departmcnt of Health and Human Services (DHHS)

is the principal U.S. government agency assigned to
protect the health of all Americans and for providing
essential human services for those unablc to help themselves. The goals of the DHHS, according to the stratcgic
plan for fiscal years 2001 -2006,"' include reducing the
major threats to the health and productivity of all Americans, improving economic and social well-being, improving access to health services, improving the public
health systems, and strengthening the nation's health
sccnce research productivity. The DHHS accomplishes
this mission through more than 300 programs under
the leadership of the Office of the Sccretary. DHHS
programs are administered through 11 operating divisions
utilizing ncarly 62,000 employees and a budget approaching $400 billion."'

Many of DHHS' divisions are managed by the Public

Health Servicc's (PHS) commissioned officers with the
assistance of civil service employees. The commissioned
officers corps consists of pharmacists, physicians, dentists, nurscs, and other health care professionals. These
officers and crnployees cngage in clinical care, medical
research, and disease surveillance through the DHHS divisions. Before the formation of the commissioned corps,
were already serving the American population through the Marine Hospital Servicc, which c a r d
for merchant seaman in large seaport citics.12' The services of the PHS expanded beyond seaports when Congress discovered the poor health care and living conditions of Native Americans under thc authority of the
Dcpartrnent of Interior's Burcau of Indian Affairs. In
1954, Congress transferred the care of all Native Americans from the Department of the Interior to the Department of Health, Education, and Welfare. With the
creation of thc Departmcnt of Education through thc
Encycloprdia
Clinical Phcirrrzacy
DOI: 10.108I/E-ECI' 120006180
Copyright 0 2003 by Marcel Dekker, Inc. All rights reserved.

signing of thc Departmcnt of Education Organization Act

in 1979, the current DHHS officially succeeded thc Dcpartment of Health, Education, and Welfare.
Throughout history, the divisions of DI-1HS have influenced many aspects of pharmacy practice and continue
to have an impact on it today. Pharmacy practice is influenced by legislation administcred through the DllHS
divisions, through the funding of grants to support health
care for the underprivileged and through rcscarch and the
funding of rcsearch to monitor and improve health scrvices. Each division plays a unique rolc in providing and
improving health care.

Although now considered the premier medical research

organization, NTH's roots bcgan in 1887 as a one-room
laboratory, known as the Hygienic Laboratory, on Staten
Island, Ncw York. Thc laboratory was opened under the
direction of Surgeon Gcneral John Hamilton to study
major epidemics of the ninetecnth century, including
cholera, ycllow fever, Rocky ountain spottcd fever, and
hookworm.'21 The importance of the Hygienic Laboratory's work prompted legislation to move it to Washington, DC. Finally, in 1930, the ansdcll Act created the
NIH to replace thc Hygicnic Laboratory. NIH researchcrs
continue to investigate the causes of and cures for the
nation's most devastating diseases. Currently, the 17 scparate health institutcs of the NIH arc focusing large
amounts of its nearly $18 billion budget on cancer,
Alzheimer's disease, diabetes, arthritis, and acquired
immunodeficiency syndrome (AIDS).'" Along with performing research, NTH also supports ncarly 40,000 research programs nationwide.

The FDA is responsiblc for assuring thc safety of foods

and cosmetics, along with the safety and efficacy of phar251

252

maceuticals, biological products, and medical devices.[41

This authority to monitor medications and foods was first
granted by Congress with the Food and Drug Act in
1906.r5.61Assuring compliance with this important act remains a key function of the FDA.
Since 1906, various amendments to the Food and Drug
Act have greatly influenced the practice of Pharmacy.
The Sherley Amendment of 1912 was the first legislation
to regulate the labeling of medications. The amendment
mandated a guarantee against adulteration and misbranding from manufacturers.
The Delaney Clause, named for Congressman James
Delaney, remains an important part of the 1958 Food Additives Amendment and the 1960 Color Additive Amendments to the Food, Drug, and Cosmetic Act. The clause
states that no additive shall be deemed to be safe if it is
found to induce cancer when ingested by man or animal 151 at any dose. The clause also recognizes and accepts that evidence of carcinogenicity in animals is sufficient to correlate to a risk in man. Examples of the FDA
invoking the Delaney Clause include the removal of
cyclamates, aminotriazole, and DDT from human food.
Modernization of the act, to allow for a negligible risk
standard, rather than the current zero risk, is currently
being pursued.
The Kefauver-Harris Amendments of 1962 gave the
FDA control over prescription drug advertising. According to the amendment, all advertisements and printed
matter issued by a manufacturer must include the medication name, strength, side effects, contraindications, and
information on effectiveness. Another major change to
the act was the requirement that all medications must be
shown to be effective, as well as safe. After this amendment, all new drug applications submitted to the FDA
must contain research proving the effectiveness of the
product. At that time, control over investigational medications and the inspection of factories was also transferred to the FDA.
Another amendment to the Food, Drug, and Cosmetic
Act is the Nutrition Labeling Health and Education Act
(NLHEA) of 1990. NLHEA is intended to provide
consumers with information to help maintain healthy
dietary practices and to protect consumers from unfounded health claims. NLHEA provides information to consumers by requiring nutrition labeling on all foods and
dietary supplements. These nutrition labels must include
the serving size, and number of servings per package,
along with the amount of calories, fat, saturated fat,
cholesterol, sodium, carbohydrates, sugars, dietary fiber,
and total protein per serving. NLHEA also ensures the
validity of nutrition claims by reviewing research sub-

Department of Health and Human Services

mitted by manufacturers to ensure the claim meets with

significant scientific agreement.

Centers for Diseas

The roots of the CDC, the agency responsible for

protecting health, are traced back to World War 11. At
that time the Malaria Control in War Areas (MCWA)
attempted to control the spread of malaria among servicemen, along with preventing the introduction of the
disease into the civilian population.[*] After the war, the
importance of continued monitoring of infectious diseases
prompted the conversion of MCWA to the Communicable Disease Center in 1946, the predecessor of the modern CDC. Today, the CDC monitors disease trends,
investigates outbreaks and health risks, fosters healthy
environments, and implements illness prevention measures and standards. The research performed by the CDC
is primarily field research, as compared with the laboratory research that is performed by the NIH. More than
7500 employees and $3 billion per year are necessary to
accomplish these goals.

ealth Services (IHS)

Although federally funded health services for Native
Americans began in the early 19th century, the Transfer
Act of 1954 propelled Native American health toward
its modern form. This law transferred responsibility for
the health care of Native American and Alaska Natives to
the PHS. Soon after the transfer the PHS was directed by
Congress to conduct health surveys of Native American
populations. The first study was the Trachoma Study. This
study found a widespread trachoma epidemic, along with
increased incidence of other infectious diseases, including tuberculosis, among this population. These results
prompted moves to improve sanitary living conditions
and expand the provision of health care available to
Native Americans.
Another PHS survey, the Meriam Report, also pushed
for advances in Native American health care. Among
the Meriam Report findings were that 1 out of 10 Native Americans had tuberculosis and over one-third of
all Native American deaths were children under 3 years
of age. These findings prompted moves for stronger
health program supervision with more qualified staff
and the establishment of health clinics on Native American reservations.
The findings of all the PHS surveys led to the formation of the current Indian Health Services as the fed-

Department of Health and Human Services

era1 agency responsible for providing health services to

Native American and Alaska Natives. These services are
currently provided to nearly 1.5 million persons in more
than 550 federally recognized tribes in 35 states[71with
the goal to assure that comprehensive, yet culturally
acceptable, personal and health services are available
and accessible. The IHS currently maintains 36 hospitals, 58 health centers, 4 school health centers, and 44
health stations. With the health care provided by the
IHS, the Native American life expectancy has increased
12 years since 1973,[71with decreased infant and maternal pneumonia and influenza, tuberculosis, and gastrointestinal mortality. Despite these advances, IHS
continues to work to reduce deaths due to alcoholism,
accidents, diabetes mellitus, homicide, and suicide. The
rates of death due to these causes remain significantly
higher in the Native American population than the rest
of the U.S. population.

Health Resources and

Services Administration (HRSA)
HRSA provides the leadership necessary to achieve integration of service delivery to meet the health needs of
Americans. This is done through the provision of personnel, educational, physical, and financial resources.
Part of HRSAs S4.8 billion budget funds more than 3000
health clinics to provide medical care to more than 9
million individuals in underserved communities each
year. HRSA also administers the Migrant Health Program,
which provides grants to communities to support culturally based medical services to migrant and seasonal
farmworkers and their families.
Although HRSA administers many diverse programs,
one of the major programs is the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act,
Public Law 101-381.s1 The Ryan White CARE Act is
named in memory of an Indiana teenager who increased
awareness about the needs of people with AIDS while
suffering from the disease himself. This act helps states,
communities, and families to ease the burden of the
AIDS epidemic. HRSA estimates 500,000 individuals
with HIV and AIDS receive assistance through this act
each year.[]
The Ryan White CARE Act is divided into multiple
parts with each part providing support to different segment of the AIDS community. The first part of the CARE
Act, Title 1, provides grants to cities and large numbers
of low-income, underinsured, or uninsured individuals
with HIV and AIDS. These grants are intended to provide outpatient health care, prescription medications,

253

home health services, hospice care, counseling services,

and housing and transportation assistance. Title 2 of the
CARE Act provides grants to states, Washington, DC,
Puerto Rico, and other United States territories to provide health care to individuals living with HIV and
AIDS. Title 2 is aimed at prolonging life and preventing
hospitalization, particularly through assistance with obtaining medications through the AIDS Drug Assistance
Program. With more than $150 million in funding from
the CARE Act, the AIDS Drug Assistance Program allows states to establish programs to purchase and distribute antiretroviral therapy for low-income individuals.
The third section of the act, Title 3, provides funds to
public and nonprofit organizations to support early intervention services for low-income, medically underserved
people at risk for HIV. These services are designed to
slow the spread of HIV through education, counseling,
testing, and early treatment. Title 4 provides grants to
establish services for children, women, and families. In
1996, Part F was added to the CARE Act to combine
other existing AIDS programs under the HRSA umbrella. Included in Part F are AIDS Education and Training
Centers that train health care providers about the necessity of early intervention and appropriate treatment,
Dental Reimbursement Programs that provide grants to
dental schools to assist in covering costs incurred in
providing treatment to HIV patients, and the Special Projects of National Significance Program that provides
grants to develop models for providing care to persons
with HIV in special populations.

Substance Abuse and Mental Health

Services Administration (SAMHSA)
Although the Narcotics Division of the PHS (later renamed the Mental Hygiene Division) was created in
1929 to treat and study addiction, the National Mental
Health Act of 1946 was the first legislation to authorize
research and aid for mental health services. Starting in
1973, this act was administered by the Alcohol, Drug
Abuse and Mental Health Administration (ADAMHA)
through the National Institute of Mental Health (NIMH),
the National Institute of Alcohol and Abuse and Alcoholism, and the National Institute on Drug Abuse. The
current SAMHSA did not replace ADAMHA until 1992.
SAMHSA continues ADAMHAs work to improve the
quality and availability of substance abuse prevention,
addiction treatment, and mental health services. The goal
of SAMHSA is to reduce illness, disability, and death,
along with the cost to society, which result from substance abuse and mental illness. SAMHSA is able to

254

provide federal grants to states to support programs

intended to eliminate the stigma associated with substance abuse and mental illness, to disseminate information to improve available services, and to develop
standards for the treatment of addicted and mentally
ill persons.

ATSDR, one of DHHS newest agencies, works to prevent exposure to hazardous substances from waste sites.
The agency develops toxicological profiles of hazardous
chemicals found at waste sites on the U.S. Environmental
Protection Agencys National Priorities List. Its 400 employees also provide health education training in communities near these waste sites.

Since its establishment in 1989, AHRQ has sponsored and

conducted research to improve the quality of health care,
reduce its cost, and increase access. It also supports research to address patient safety issues and medication
errors. AHRQs goal is to provide information that allows
people to make better decisions about healthcare.

Department of Health and Human Services

i ~ i s ~ r a for
t ~ o ~ ren an

The ACF, established in 1991, maintains more than 60

programs that promote the economic and social wellbeing of children, families, and communities. Many of
ACFs programs are aimed at helping children, with the
most widely recognized being the Head Start Program.
Head Start works with children from birth to 5 years of
age, pregnant women, and their families to increase the
school readiness of children from low-income families.
ACF also funds programs to prevent child abuse and domestic violence. ACF continues to administer a national
enforcement system that works to collect child support
payments from noncustodial parents.

Establishment of the AoA was mandated as part of the

Older Americans Act of 1965. The Older Americans Act
was passed as a means to organize, coordinate, and provide community-based services and opportunities for older
Americans and their families. Although AoA programs
are available to all Americans 60 years of age or older,
priority is given to those with the greatest need. AoAs
work is intended to protect the rights of vulnerable and
at-risk persons, educate the community about the danger
of elder abuse, and provide employment opportunities
for older Americans.

an Services (0s)

The primary responsibilities of CMS, formerly known as

Health Care Financing Administration (HCFA), include
administration of Medicare and Medicaid programs. Since
1965, Medicaid has provided health coverage for lowincome persons, while Medicare has provided for the
elderly and disabled. Medicaid currently provides coverage for more than 34 million people, including nearly
18 million children. Medicare currently provides coverage
for more than 39 million elderly and disabled Americans.] CMS requires a budget of $325.4 billion to
provide these and other services. Among CMS other
responsibilities is administration of the Childrens Health
Insurance Program. The Childrens Health Insurance Program provides reduced or no-cost health coverage for
more than 2 million children under the age of 19 whose
families earn too much to be eligible for Medicaid but do
not earn enough to afford private insurance.

The Office of the Secretary provides leadership for the

entire DHHS. It is responsible for advising the President
on issues relating to health and welfare. The most recent
expansion in the OS is the formation of the Office of
Public Health Preparedness (OPHP) in late 2001. This
office was created in response to the terrorist attacks on
September 11, 2001. The OPHP directs the DHHS activities aimed at protecting the population from acts of
bioterrorism and other public health emergencies. Working with the Office of Homeland Security, OPHPs efforts
are aimed at coordinating the preparation for and recovery
from such events.

ram Support Center (

The final DHHS agency, PSC, provides administrative
support for the DHHS. PSC is a self-supporting division
that operates as a business-like enterprise. Their mission

429

Health-Systems, Clinical Pharmacy Careers in

director of pharmacy services to supervisor of a segment

of the pharmacy services within the health system. Some
examples of pharmacy manager positions include supervisor of the drug information service, supervisor of the
therapeutic drug monitoring service, supervisor of ambulatory care services, supervisor of community pharmacies,
supervisor of clinical services, and assistant director of
pharmacy services.

TlVlTlE
The typical work settings for clinical pharmacists in a
health system include acute care hospital, ambulatory
clinic, outpatient pharmacy, home care pharmacy, and
community pharmacy.
Clinical practice in the hospital could be in the central
hospital pharmacy, a satellite pharmacy, a pharmacists
office, or a patient care area. The hospital pharmacy is
usually located on a lower floor of the facility, which
places the pharmacist physically remote from the patient,
physician, nurse, and other personnel. Communications
are often by telephone, fax, or information technology
rather than in person. A satellite pharmacy is a pharmacy
area located in the patient care area where drug distribution and clinical services are provided. A satellite
pharmacy places the pharmacist in the patient care area
where drug distribution and clinical services are provided.
A satellite pharmacy facilitates the placement of pharmacists in close proximity to the patients, physicians, and
nurses. A pharmacists office space is often provided as a
location for the pharmacist to provide clinical services
that is in close proximity to patients, physicians, and
nurses. Clinical services can be provided in a drug information center, often located in the hospital pharmacy,
but it may be located in the medical library. Therapeutic
drug-monitoring services may be provided from a pharmacists office location.
Clinical practice in an ambulatory clinic may be provided from an office area within the clinic. The patient,
patient medical record, physician, nurse, and other practitioners are in close proximity to the pharmacists office
area. Examples of clinics in which pharmacists have provided clinical services include family practice, OB-GYN,
anticoagulation, prescription refill, pain therapy, nutrition,
and internal medicine.

The health system may own one or more community

pharmacies. Clinical services can be provided relating to
patient drug therapy counseling for prescription and

nonprescription medications, management of dmg therapy via physician-approved guidelines, monitoring of

drug therapy, and screening tests for hypertension, diabetes, and hypercholesterolemia.

ral
The following list of pharmacist practice activities describes a general clinical practice model:
Clarify prescription orders.
Question inappropriate prescription orders.
5
Answer drug information requests from patients.
* Answer drug information requests from physicians,
nurses, and other health professionals.
Monitor patient drug therapy for safety and efficacy
using a comprehensive patient medication record:
5

Drug-drug interactions.

- Concomitant drug therapies.

- Appropriate drug, dose, and dosage form.
- Patient allergies.

Drug-laboratory test interactions.

Drug-food interactions.
- Abnormal laboratory tests that are drug induced.
- Clinical pharmacokinetics.
-

Provide patient medication counseling.

Provide screening tests.
Participate in collaborative practice agreements for
managing drug therapy.
* Participate in clinical research.
e
5

XPERl
The preferred education for a health system pharmacist is
the doctor of pharmacy degree. A general practice residency is also preferred. Some clinical pharmacist practices prefer pharmacists with a specialty residency. The
American Society of Health System Pharmacists for the
past 25 years has adopted policies and provided programs
to support these preferred education and training programs. When the criteria can be met for board certification, many health systems support clinical pharmacists
in becoming board certified.
Pharmacist clinical expertise requires practice, practice, and more practice. Years, usually three to five, are
often acceptable to health systems in lieu of some residency training. The challenge is to get appropriate clinical practice experience without a residency.

Health-Systems, Clinical Pharmacy Careers in

430

For supervisory positions, three to five years of

practice experience is often required. During the practice
experience, the pharmacist should demonstrate the ability
to achieve results, complete objectives on a timely basis, possess good communication skills, and demonstrate
good working relationships with coworkers, physicians,
and nurses.
For director of pharmacy services, five to seven years
of experience are often required in a similar health system. Additional education and training, such as an advanced residency in pharmacy management or a masters
degree in business administration, are often preferred or
required. Ability to manage resources, personnel, planning, financial, and interprofessional relationships with
good communication skills are often required.

The following sites are examples within health systems

where pharmacist clinical services are provided:
e
e
e
e
e

e
e
e
e
0

e
e
e
e

Career ladders and growth within a health system can be

viewed as longitudinal andlor lateral. Longitudinal would
be from staff pharmacist to director of pharmacy services. Lateral would be clinical pharmacist from acute to
home care.
The usual longitudinal path is staff pharmacist to
clinical pharmacist, to supervisor of clinical services, to
assistant or director of pharmacy services. Each practice
along this path requires demonstrating knowledge, skill,
and the ability to learn more; assuming new responsibilities; and successfully performing the duties and responsibilities of each position. Additional education and
training often will speed the time line for the longitudinal
career path.
The lateral career path relates to clinical practice at
different patient care levels or settings. Acute care to
ambulatory and/or home care was often required in the
1990s as health systems expanded ambulatory and home
care services and reduced acute care services.
Directors of pharmacy may be asked to assume the
management of other departments and programs within
the health system. The pharmacy director may continue as
director or may give up the management responsibility for
pharmacy services.

A~VANTAGESOF W ~ R K ~ NINGTHE

Several of the obvious advantages for working as a pharmacist in a health system include:
e
e
e
c
e

e
e

e
e
e

ClST
E
Pharmacist clinical services can be provided at any site or
location of patient care. These services are provided directly to patients or indirectly to patients through the
nurse and/or physician.

Acute care hospital in the patient care area(s).

Critical care unit.
Pediatrics hospital.
Neonatal intensive care unit.
Long-term care facility.
Family practice physician office.
Ambulatory care clinic.
Home care services pharmacy.
Community pharmacy.
Outpatient pharmacy.
Drug information services.
Therapeutic drug monitoring service.
Oncology.
Hospice.

Direct access to patients and patient information.

Availability of physicians and nurses.
Patient care environment.
Levels of care-primary, secondary, tertiary.
Resources to support pharmacist clinical services.
Patient care quality assurance activities for pharmacist
participation.
Hospital and medical staff committees for pharmacist
participation.
Opportunities for clinical research.
Opportunities for participation in education programs
for physicians, nurses, and patients.
Provision of drug information on a daily basis.
Participation in therapeutic drug-monitoring services.
Collaboration with pharmacist colleagues in clinical
practice.
Participation in teaching programs for pharmacy
students and residents.
Demand to know acute care pharmacotherapy.

These examples translate into a demand for the pharmacist to know pharmacotherapy and a requirement to
update clinical therapeutics knowledge and expertise; to
collaborate and work effectively and efficiently with
physicians, nurses, and pharmacist colleagues in providing services and care to patients; and to participate in the

43 1

~ e a ~ ~ h " ~Clinicat
y ~ ~ Pharmacy
c ~ ~ s , Carecrs in

many varied activitie5 to provide yuality care to patientc

at different level\ ot care

What is the job satisfaction and morale of the pharmacist staff?

How arc pharmacy technicians used in the pharmacy
operations'?
What i \ the compensation and benefit package'?
What i j the strategic plan for the health \ystem and for
the pharmacy services?

A broad categorintion or hospitals is government and

nongovernment. Government hospitals are federal, state,
and local. Nongovernment hospitals can be categoriLcd
into nonprofit and proprietary (for-profit). A teaching
hospital is one that provides a postgraduatc education
program for physicians. All hospitals exist to provide
services and care to the patients being served. Some of the
key differences between hospitals include the management decision-making process, type of medical staff,
scope of patient services to be provided, size, and financial objectives and strength of each hospital. Thcrc is
not an existing method to determine which types of
hospitals provide more pharmacy and pharmacist clinical
services as there are too many variables that determine the
existing scope of pharmacist services. In general, every
hospital needs more clinical services from the pharmacy
department and staff than currently exist.
Some questions to consider whcn looking at a health
system for possible cmploymcnt include the following:
What is the existing scope of pharinacist clinical
services? What types of services? How long havc they
been provided?
Is the hospital a teaching hospital'?
Does the pharmacy havc an afliliation with a school
of pharmacy?
Docs the health system provide pharmacy residencies?
What is the pharmacy director's philosophy regarding
pharmacist clinical services?
How docs the pharmacy facilities look regarding to
size, organization, cleanliness, automation, and drug
information resources'?
Docs the medical staff and health-system administration support pharmacy services and pharmacist clinical
practice activities?

The answers to these and similar questions should convey whether the health system being considered will provide an environment for clinical practice, job satisfaction,
and opportunities for growth and career advanccmcnt.

PI

Some key factors for seeking pharmacist employment in

a health system relate to the opportunities to provide
clinical services directly to patients, to collaborate with
physicians and nurses, to copc with the personal challenge t o maintain and expand clinical pharmacotherapy
knowledge and expertise, to change practice settings for
the different levels of care and job satisfaction, and to
be viewed as an essential health care practitioner by the
institution, physician, and nurse colleagues. The personal
satisfaction from providing clinical services that benefit
patients is the best reward for working in a health-systein environment.

ACCP Guideline, Practicc guidelines for pharmacotherapy specialists. Pharmacotherapy 2000. 20, 487 490.
ACCP Position Statement. Position papcr on critical carc pharmacy services. Pharmacothcrapy 2000. 20, 1400 1406.
ACCP While Paper. Clinical pharmacy practice in the noninstitutional sctting. Pharmacotherapy 1992. 12. 358-364.
ACCP White Paper. Establishing and evaluating clinical pharmacy services in primary carc. Pharmacotherapy 1994, 14,
743 7 58.
~

PHARMACY PRACTICE ISSUES

Carl

I. Tullio

Pfizer, Inc., Yorktown, Virginia, U.S.A.

Healthy People 2010 is a national health promotion and

disease prevention program aimed at improving the health
of all Americans. Progress in reaching these goals will be
measured using 467 objectives organized under 28 focus
areas. Healthy People 2010 is important to pharmacists
because many of the objectives involve the use, or the
need for proper use, of medications. This article provides
a short history of this program. Using diabetes as an
example, it explains the content of the focus areas, then
reviews the goals and how progress toward them is
assessed. Finally, the implications for pharmacists are
presented. (All of the information in this article is from
the Healthy People 2010 Web site, http://www.health.
gov.healthypeople/.)

201

Healthy People 201 0: Objectives f o r Improving Health,

the third decade-long national initiative, builds on the
achievements of the past two decades. In 1979, the first
report, Healthy People: The Surgeon Generals Report on
Health Promotion and Disease Prevention, put forth
national goals for preserving independence for the elderly
and reducing premature deaths. A second report, in 1980,
Promoting Health/Preventing Disease: Objectives f o r the
Nation, provided more than 200 health objectives for the
United States to achieve over the next 10 years. Healthy
People 2000: National Wealth Promotion and Disease
Prevention Objectives, released in 1990, continued this
program and identified health improvement goals and
objectives to be attained by the year 2000. The Healthy
People 2010 initiative continues in this tradition as a tool
to improve our nations health into the first decade of the
2 1st century.
One of the most encouraging lessons learned from the
Healthy People 2000 program was that we, as a nation,
can make dramatic progress in improving the nations
health in a relatively short period of time. For example,
432

during the last decade, significant reductions were

achieved in infant mortality. Childhood vaccinations
are at the highest levels ever recorded in the United
States. Fewer teenagers are becoming parents. Overall,
alcohol, tobacco, and illicit drug use is leveling off. Death
rates for coronary heart disease and stroke have
declined. Significant advances have been made in the
diagnosis and treatment of cancer and in reducing
unintentional injuries.
But there is still much progress to be made. Diabetes
and other chronic conditions continue to present a serious
obstacle to public health. Violence and abusive behavior
continue to ravage homes and communities across the
country. Mental disorders continue to go undiagnosed and
untreated. Obesity in adults has increased 50% over the
past two decades. Nearly 40% of adults engage in no
leisure time physical activity. Smoking among adolescents has increased in the past decade. And HIV/AIDS
remains a serious health problem, now disproportionately
affecting women and communities of color. The development and implementation of Healthy People 2010
will be the guiding instrument for addressing these health
issues, reversing unfavorable trends, and expanding on
past achievements.

EV
Suggestions for Healthy People 2010 objectives were
gathered from a variety of diverse organizations and
people using a series of national and regional meetings.
On two different occasions in the late 1990s, the American public was given the opportunity to express its
views and opinions. More than 11,000 comments were
received from every state in the Union, plus the District
of Columbia and Puerto Rico. Using this input, the final
Healthy People 2010 objectives were developed by teams
of experts from various federal agencies under the
direction of Health and Human Services Secretary Donna
Shalala, Assistant Secretary for Health and Surgeon
General David Satcher, and former Assistant Secretaries
for Health. The Office of Disease Prevention and Health
Eizcjclopedia of Clinical Pharmacy
DOI: 10.1081E-ECP 120006190
Copyright 0 2003 by Marcel Dekker, Inc. All rights reserved.

433

Healthy People 2010: Objectives for Improving Health

Promotion, U.S. Department of Health and Human Services, coordinated and oversaw the entire process.

ENT
The two overarching goals of Healthy People 2010 are
the elimination of disparities in health status among racial
and ethnic groups and the improvement in the years and
the quality of life for people of all ages. Progress in
attaining these goals will be measured using the 467
objectives in the 28 Focus Areas (Table 1). Each focus
area contains its own overarching goal. For example, the
goal of the diabetes section states, Through prevention
programs, reduce the disease and economic burden of
diabetes, and improve the quality of life for all persons
who have or are at risk for diabetes. After listing the
goal, an overview of the issues, trends, disparities, and
opportunities for action is presented. If the topic was
included in the previous program, Healthy People 2000,
interim progress toward the objectives is detailed. Using
the diabetes example, there are five objectives in the

previous initiative. As Healthy People 2000 draws to a close,

one objective is trending toward the goal, while the other four
are trending away from the goal.

Next, the focus area objectives for 2010 are presented.

Each focus area contains varying numbers of objectives.
Many of the objectives are aimed at interventions designed to reduce or eliminate illness, disability, and
premature death among individuals and communities.
Others focus on broader issues, such as improving access
to quality health care, strengthening public health services, and improving the availability and dissemination of
health-related information. In the diabetes example, the
number of objectives was increased from 5 in the 2000
program to 17 for the current program. Each objective
(e.g., increase the proportion of persons with diabetes
who receive formal diabetes education.) lists a target
(e.g., 60%) for the year 2010, the rationale behind its
focus, and the national data tables from which the
measurements will be extracted. Each focus area ends
with a listing of related objectives from other focus
areas, an explanation of the terminology used, and the
references employed.

Fable 1 Focus areas for Healthy People 2010

~~

Access to quality health services

Arthritis, osteoporosis, and chronic back conditions
Cancer
Chronic kidney disease
Diabetes
Disability and secondary conditions
Educational and community-based programs
Environmental health
Family planning
Food safety
Health communication
Heart disease and stroke
HIV
Immunization and infectious disease
Injury and violence prevention
Maternal, infant, and child health
Medical product safety
Mental health and mental disorders
Nutrition and overweight
Occupational safety and health
Oral health
Physical activity and fitness
Public health infrastructure
Respiratory diseases
Sexually transmitted diseases
Substance abuse
Tobacco use
Vision and hearing
(Ref. http://www.health.gov.healthypeople/.)

In order to periodically assess the health of the nation, a

set of leading health indicators was developed for the first
time (Table 2). These indicators, which address major
public health concerns, were chosen based on their
ability to motivate action, the availability of data to
measure progress, and their relevance as broad public
health issues. For each of the leading health indicators,
specific objectives from Healthy People 2010 were
selected and will be used to track progress. This small
subset of measures will provide a snapshot of the health of
the nation. Even though the leading health indicator may
have the same name as a focus area, the indicator may
Table 2 Leading health indicators for Healthy People 2010
Access to health care
Environmental quality
Immunization
Injury and violence
Mental health
Overweight and obesity
Physical activity
Responsible sexual behavior
Substance abuse
Tobacco use
(Ref. http://www.health.gov.healthypeople/.)

434

contain only a few of the focus areas objectives and may

even contain objectives from a related focus area. For
example, the tobacco use focus area has 21 objectives,
while the tobacco use leading indicator follows only 2 of
the objectives. The indicators will highlight achicvements
and challenges throughout the next decade while serving
as a link to the 467 objectives of the Healthy People 201 0
program. The leading health indicators are intended to
help thc populace more easily understand the importance
of health promotion and disease prevention. They are also
aimed at encouraging wide participation in improving
health in the next decade.

Healthy People 2010 is important to pharmacists in all

arcas of practice. The focus areas and their objectives
address not only clinical issues but also social issues. As
pharmacists push forward into true pharmaceutical care,

ealthy People 2010: Objectives for Improving Health

the entire patient must he considered, not just the medical

management. Healthy Pcople 201 0 provides thc information needed to help pharmacists develop services that are
aligned with national goals.
For detailed information, the full text of Healthy
People 2010 Conference Edition (Volumes 1 and 2) is
available online at http://www.health.gov.healthypeop1e/.
A CD-ROM version (B0071) can bc purchased from
ODPHP Communication Support Center, P.O. Box
37366, Washington, D.C. 20013-7366, (301) 4685960. Limited numbers of the print version (B0074)
are also available from the ODPHP Communication
Support Center.

Healthy People 20 10: Objectives for Improving Health. http://

www.health.gov.healthypeople/ (accessed October 10, 2000).

PROFESSIONAL DEVELOPMENT

Donald J. Filibeck
Mt. Carmel Home Infusion, Columbus, Ohio, U.S.A.

The practice of clinical pharmacy in the home care/home

infusion setting is a challenging, but rewarding practice
site. The pharmacist is a vital member of the home care
team, which includes the patient and/or their caregiver,
the physician, the home care nurse, and various other
support personnel (e.g., pharmacy technicians, customer
service personnel, billing personnel). The practice sites
vary greatly, and many clinical, operational, and marketing opportunities exist.

at home looks good, as it is approximately one-third as

costly as providing care in the hospital.
As an alternative, some infusion pharmacies also
provide infusion therapies in an ambulatory cliniclike
setting. This arrangement has the advantage of providing
services to patients in a supervised setting. It allows
several patients to receive their infusions concurrently,
therefore making more efficient use of the organizations
staff, particularly nursing.

RMACIST IN HOM

Home infusion therapy involves the administration of

medications using the intravenous, subcutaneous, or epidural routes. Therapies administered at home include
antiinfectives, chemotherapy, pain management, parenteral or enteral nutrition, and immunologic or biological
agents. Many different diagnoses are treated at home,
including many infectious diseases (bacterial, fungal, or
viral), gastrointestinal diseases, immunologic disorders,
and cardiac diseases (e.g., congestive heart failure).-]
Home infusion therapy has proven to be a safe and
effective alternative to patients receiving care in hospital
settings. For most patients, receiving treatment in the
home (or in an outpatient clinical setting) is preferable to
being kept in a hospital.
Whenever a patient starts on home infusion therapy, a
prescription from a qualified physician responsible for the
care of the patient is needed. Home nursing services are
also generally provided to ensure that the proper patient
education and training occurs, and to provide ongoing
clinical monitoring of the patient in the home, along with
the pharmacists clinical interventions.
From a business perspective, the home infusion market
is projected to have annual revenues approaching $4.5
billion (year ending 2000). The market continues to experience cost-containment pressures (as does the entire
healthcare market); however, the future for providing care

Encyclopedia of Clinical Pharmacy

DOI: 10.1081E-ECP 120006263
Copyright 0 2003 by Marcel Dekker, Inc. All rights reserved.

The staff pharmacist may or may not have an advanced degree (i.e., Doctor of Pharmacy degree). Although a PharmD degree is not required, it does ensure
that the pharmacist has a good, sound clinical education. More important is the persons ability to think
quickly when asked difficult questions or when in difficult situations; to interact professionally with a wide
range of individuals (both clinical and nonclinical); and
to be able to work with little supervision in an often
unstructured environment.
As a manager, when hiring, the persons previous
work history should be evaluated for these abilities.
However, experience working in the home care environment is not an absolute requirement. There are pros
and cons to hiring someone with experience. The person
must be licensed in the state in which they are practicing
and must meet all continuing education requirements.

WORK E N V I ~ O N M ~ N T S
Typical work environments are office-type settings where
the pharmacist is working alongside many different individuals. The sites may be free standing (located in light
industrial or suburban office parks) or located on a health
system campus. Many health systems provide home care/
home infusion services as part of the for-profit arm of the
system. In those cases, the home infusion provider pro-

435

436

Home Care, Clinical Pharmacy Careers in

vides service for only those patients being discharged

from the hospital.
For-profit home infusion providers range from singlesite, private companies to multiple-site, million-dollar
companies. All home care providers are licensed by the
state and can chose to become accredited by several accrediting bodies (e.g., Joint Commission on Accreditation
of Healthcare Organizations (JCAHO), Accreditation
Commission for Health Care, Inc. (ACHC), Community
Healthcare Accreditation Program (CHAP)). Accreditation is a requirement for many insurance companies to
serve as a provider for their members.
An advantage of working in home care is the flexibility
in hours and activities that the home care environment
offers. Positions are available that range from PRN or, to
as needed, to part and full time. As needed positions are
often used to help cover vacations and scheduled time off
or on-call activities. Part-time positions can range from
1 or 2 days per week to 4 or 5 . Average hours per day are
8 or 10 depending on the home care company.
Because home care personnel must be available 24
hours per day, on-call related activity may be required.
Depending on the organization and workload activities,
afternoon, evening, or weekend shifts may be used.

CTI~ITI~S
OF THE HOM
Activities vary greatly, depending on the services provided and the size of the operation. In small offices, the
pharmacist may wear many different hats. In large offices,
the pharmacist may do only one task on a given day.

Table I

Home care preadmission criteria

Patientlcaregiver agrees to receive services in the home.

Patientlcaregiver are willing to learn the necessary steps to
administer their drug(s) in the home.
4
The home environment is acceptable (clean, access to telephone and running water).
0
The patient is readily accessible to the home care provider.
* The patient has adequate family support, both physically and
psychologically.
4
A physician is readily available in the event of an emergency,
ongoing clinical updates, and/or order changes.
* The medication ordered is appropriate to be given in the
home environment.
* The indication, dosage, and route of administration of the
medication(s) ordered is appropriate.
e Labs etc., are ordered to access the effectiveness of the therapy ordered.

Table 2 Home care patient database

4

*
4
0

*
*

*
e

*
*
*
*

Patients name, address, phone number, date of birth.

Alternate contact information in the event of an emergency.
Information on the status of any advance directive.
Height, weight, gender.
Diagnoses.
Location and type of intravenous access and date of
placement.
Pertinent laboratory test results.
Pertinent medical history and physical findings.
Accurate history of allergies.
A detailed medication profile, including all prescription and
nonprescription medications, home remedies, and investigational and nontraditional therapies.
Other agencies involved in patient care.
Prescribers name, address, phone number, etc.
A plan of care.
Patient education activities.
Anj7 functional limitations.
Any pertinent social history.

Tasks include dispensing-related functions; technician

oversight; obtaining orders from physicians and then assessing the orders for appropriateness; assessing the patient and caregiver for the appropriateness of providing
care in the home; patient and/or caregiver education;
providing education for nursing agencies, discharge planners, etc; answering drug information questions; sales
support; and so on. No one day is ever the same. The following explains these activities in greater detail.
One of the primary roles of the pharmacist is the preadmission assessment. This role ensures that each patient
is assessed for appropriateness using predetermined admission criteria. Common criteria are outlined in Table 1.
In conjunction with other members of the home care
team and with the patients physician, a decision is made
to either accept the patient for home care services or refer
them back to the hospital discharge planner or referral
source. Once accepted, an assessment is completed and an
initial patient database established. Table 2 lists some
of the items that are part of this database. Again, the
pharmacist is an integral part of this process. Much of this
information is obtained via the telephone in conversations
with the physician, hospital personnel, or patient. Information may also be received via fax or from the home
care agency nurse. Pharmacists working in a hospitalbased home care pharmacy may be able to go up to the
floor and obtain this information directly from the medical record, floor nurse, and/or patient.
One of the documents that is part of this patient database is the care plan or plan or care. The plan of care
should indicate the treatment goals and indicators of de-

ome Care, Clinical Pharmacy Careers in

sired outcomes. any interventions that need to be done,

and the frequency of those interventions. Any drug-related problems that occur or have the potential to occur
should be addressed by the pharmacist, along with other
members of the patient care team. When multiple providers are involved with the patient, the pharmacist is in
an ideal position to coordinate the information flow and
care of the patient.
The plan of care should be developed initially and
updated as needed. Based on the drug(s) used and the
potential for side effects and adverse drug reactions, the
pharmacist should determine what type of monitoring
is needed (e.g., labs, physical findings) and the frequency at which it is to occur. The pharmacist must communicate this plan to others involved and provide updates
as needed.
Another role of the pharmacist is the selection of products, infusion devices (i.e., pump), and ancillary supplies. Many factors need to be considered when choosing
the administration method, infusion device to use, and
what ancillary supplies are needed.
The stability, compatibility of the drug, and volume
of the drug are important considerations when determining what method (IVPB, IV push, continuous infusion)
or infusion device (elastomeric, electronic infusion device, etc.) will be used. Nursing agency knowledge and
ability of the patient to learn the methodology are all
important considerations. Patient convenience, prescriber preference, and cost must also be considered. Again,
the pharmacist is able to weigh the pros and cons of
any method and help the patient care team make appropriate decisions.
The ongoing clinical monitoring is the hallmark of the
pharmacists involvement. By having regular, ongoing
conversations with the patientharegiver, physician, and
home care nurse, the pharmacist is able to make an ob-

Table 3 Education-related issues

0

e
0
0

Medication related, including dose, route of administration,

dosage interval, duration, side effects, adverse reactions (and
their management).
Proper aseptic technique.
Precautions and directions for administering the medication.
Equipment use, maintenance, and troubleshooting techniques.
Proper care of the vascular access device and site (if applicable).
Home inventory management, how to contact help, emergency issues (what to do if something goes wrong).
Special precautions and directions for the preparation,
storage, handling, and disposal of drugs, supplies. and
biomedical waste.

437

jective evaluation of the therapy(ies), make appropriate

recommendations for changes, and effectively communicate those changes to the patient/caregiver and all involved health care providers.
On an initial and ongoing basis, the pharmacist
should be providing education to the patient and/or caregiver. Some of this information may be provided verbally, although most is provided in writing. Table 3 lists
some of these education-related issues. The pharmacist
should be involved in the development of all educational material.

s
The range of careers is very diverse. Pharmacists may
choose to remain clinically focused, providing hands-on
care to the patient. Opportunities exist to do research on
the delivery and use of drugs in the home environment.
Extended stability studies are one area where the pharmacist can become involved. If the pharmacist gets involved in clinical research, they should ensure that all
appropriate policies and procedures are followed, that the
patient and health care providers have appropriate information concerning the drug(s), and that all required
record-keeping requirements are met.
Many sites offer clinical clerkships for undergraduate
pharmacy students and several post-PharmD residencies
in home care exist.
From an operational perspective, pharmacists who
have a business background can progress from a stafflevel position to branch, regional, or corporate management positions. It is not unusual for a mid- to high-level
manager to have started out as a staff pharmacist.
The pharmacist should be actively involved in the
organizations performance improvement activities.] ASpects of care that can be monitored include, but are not
limited to, patient satisfaction, unscheduled admissions,
medication errors, adverse drug reactions, infection control-related issues (e.g., line infections), unscheduled deliveries, and so on.
The pharmacist must also take an active role in the
development, implementation, and review of an organizations policies, procedures, and protocols. The pharmacist should ensure that all aspects of care are addressed,
including patient care, drug preparation and dispensing,
quality control, infection control, and equipment maintenance. Involvement in such activities can have farreaching effects on efficiency and financial outcomes.
As a manager, the pharmacists responsibilities include: 1) setting the goals (both short- and long-term) of
the pharmacy, based on the needs of the patients and

438

mission/goals of the organization; 2) developing plans to

achieve those goals; 3) implementing those plans; 4) assessing whether the goals are being met; and 5) instituting
corrective actions when necessary.
The pharmacy manager will have multiple areas of
responsibility, such as managing the pharmacy (including compliance with laws, regulations, and accreditation
standards), financial resources (drugs, budgets, reimbursement), and pharmaceutical care and human resources (scheduling, hiring, education and training, staffing needs).
Pharmacists that have a sales/marketing nature can
pursue this career tract if so desired. As mentioned prcviously, positions range from branch salcdmarketing to
corporatewide strategic sales management.

ome Care, Clinical Pharmacy Careers in

to providc sound pharmaceutical care to the patients

receiving home care services.

1.

2.

3.

4.

5.
The practice of pharmacy in the home care environment
presents many opportunities for professional and personal
growth. T h c practice continues to evolve and will
continue to offer pharmacists multiple opportunities (both
clinically and management related), as well as continuing

6.

I.
8.

American Society of Health-System Pharmacists. ASHP

guidclines on minimum standards for home care pharmacies. Am. J. Health-Syst. Pharm. 1999, 56, 629 638.
American Society of Health-System Pharmacists. ASHP
guidelines on the pharmacist's role i n homc care. Am. J.
Health-Syst. Pharm. 2
National Home Infusion Association. White Paper: Home
ln/usion Servicrs, Payineizt Modes und Operutionnl Costs;
www.nhianet.org.
National Home Inruusion Association. Resourcrs ,for
Priyc,r:r, Physiciatzs & Providers: Overview of' Home
h@sion Therapy; www.nhianet.org.
National Home Infusion Association. Resources ,firr
.ricians & Providers: Patient Care Process in
on Thcrupy; www.nhianet.org.
www.nhianet.org.
www.ashp.org.
Winiarski, D. Performance improvement in action: Kecliveries of iiilusion supplies. Infu-

PHARMACY PRACTICE ISSUES

Ana Clopes
Hospital de la Sta. Creu i Sant Pau, Barcelona, Spain

The introduction of home care is unavoidably bound to

the changes that have been taking place in most health
systems over the last 30 years. The financial pressure to
reduce the hospital length of stay has a direct relationship on the acceptance of home care, and on the
growth of other activities such as nursing homes and
outpatient clinics.
Home care or hospital at home is defined as a service
that provides active treatment by healthcare professionals
in the patients home of a condition that otherwise would
require acute hospital in-patient care, always for a limited
time period.[
This definition is the same for all models of health
systems but the application and focus of care differ.
However, in most systems home care implies the application of high technology in the patients home for a
limited period, rather than care for chronic patients. For
this reason, in most systems, the referral centers are
the hospitals.
The concept of home care originated in the university
hospitals in the forties. In 1947 the Montefiori Hospital in
New York planned to extend the hospital to the patients
home. But home care was in fact first applied in the
sixties with Hospitalisation a Domicile in France in
1961.[21It has been implemented in a number of other
countries, including the United States,[31Canada, and the
Netherlands.14] Home care coverage within the Medicare
program in the United States was implemented in 1966.
The acceptance of home care has been faster in North
America than in European countries where there is no
direct cost to the patient or an insurer when a patient is
admitted to a hospital.[51

to different ~tudies][,~-*~
without loss of effectiveness
of treatment. A meta-analysis carried out by Hughes
et
studied the impact of home care hospital days
(22 studies) and demonstrated a significant reduction
in hospitalization days across studies due to home
care, with a cumulative effect size of -0.38 (CI,
-0.42 to -0.34, p=O.OOl).
The patients maintenance in hidher family environment. This implies an improvement in the quality of
life] and patient satisfaction. I
The patients involvement in hisher own care. This is
not typical in conventional health care and should be
considered to improve the effectiveness of treatment.
At the same time it breaks the bonds of nonpositive
dependence that sometimes exist between the patient
and the hospital.
Avoidance of the risk of nosocomial infections. Patient
care in a nonhospital environment avoids contact with
hospital organisms, which are usually more resistant to
antibiotic treatment.
Development of health models which integrate the
different areas (basically hospital and communi9
cave). The separation between the different areas of
patient care is artificial, while integration implies a
higher quality and more individualized care.

The way home care is organized depends more on the

type of care within each country than on the kind of
care provided. Home care can be classified according
to the type of reference center or according to the type
of structure.

Reference Center
The advantages of home care are:
0

Reduction in hospital length of stay.[llThis is reflected

in the decrease in costs [from 30 to 85% according

Encylopedia of Clinical Pharmacy

DOI: 10.1081E-ECP 120006376
Copyright C 2003 by Marcel Dekker, Inc. All rights reserved.

Hospital-based home care sewices

The hospital is responsible for the patients and is the
decision-making center. A hospital team organizes,
439

440

stimulates, and assumes the leadership of the inclusion

of patients in home care. High technology such as longterm ventilation,"21 intravenous antibiotics administration,[13] chemotherapy admini~tration,"~]or parenteral
nutrition"'] is included. The length of hospital stay is
reduced by early discharge of patients following
elective surgery with a home-based rehabilitation program,[1~19~

Community-based home care services

These usually include patients with chronic diseases requiring low technology. The community center medical
team visits the patient at home. Examples of programs
applying such schemes are home care programs for
diabetes, hypertension, terminally ill patients, physiotherapy at home, and care of elderly.
Programs may also consist of mixed care with
collaboration between the different areas of the health

~ l a s s ~ f ~ c a tAcc~rdin
ion
Type of ~tructure
External provider. The health care team (physicians,
nurses, and pharmacists) and the drugs and ancillary
supplies proceed from a commercial provider who has
a contract with hospital or the reference center.
A mixed structure of external provider and the reference
center. The hospital may provide the medical team and
pharmacy services, for example, and the external provider supplies the nurses and drugs.
Reference center structure. The physicians, nurses and
the pharmacy services depend on the reference center,
hospital or community centers.

Selection Criteria
Selection criteria for patients who are candidates for
home care are adapted to each environment, geographical area, and type of patient. These criteria can be
divided into medical condition and psychosocial and
family support. They will be described in each protocol
of patients' inclusion defined for each diagnosis. But
some general environments should be evaluated in all
cases: home and family environment.

Home Care Pharmacy Practice (Spain)

Home environment
A series of home requirements must be met and in all
cases assessment of the following is needed:

* Geographic access to the reference center that each

home care team will define according to the characteristics of the area.
8
A telephone is imperative for continued contact between the patient and the home care team.
* The home should be clean and have electricity and
running water. Based on this information, the pharmacist, in conjunction with the other team members,
will assess the patient's appropriateness. Other requirements such as a refrigerator will also be necessary
in some cases if the patient requires medication that
has to be stored at low temperatures.

Family environment
The presence of a caregiver is mandatory in most of the
home care protocols, although this will depend on the
therapy administered and also on the medical situation.
The home care team should assess the patient's or
caregiver's capacity to be involved in the care.

Patient's Origin
Patients evaluated for inclusion in a home care program
may proceed to a hospital, emergency room, or community care center.

Procedure for the Patient's Admission

The whole home care team is involved in patient inclusion
and care planning although each member will play a
specific role in the activities.
The steps in the admission procedure are:

1. The physician in charge of the patient considers

whether helshe will be a candidate for home care
according to the clinical assessment described in
the previously defined protocol. In the detection of
patient candidates, the pharmacist and the nurse
who are working in the home care team can also
participate.
2. Family support and home environment are evaluated by the social worker or by the nurse together
with the pharmacist, also according to the
previously defined protocols.
3. The entire home care team plans the care.

441

Home Care Pharmacy Practice (Spain)

Table 1 Infections most frequently included in home

care programs
Skin and soft-tissue infections
Cellulitis
Abscess
Postoperative wound infection
Posttrauma wound infection
Diabetic foot
Decubitus ulcer
Bone and joint infections
Acute and chronic osteomyelitis
Septic arthritishursitis
Prosthetic joint infections
IV line infection
Infective endocarditis
Ear and sinus infections (sinusitis/otitis/mastoiditis)
Acute exacerbation of pulmonary symptoms in cystic fibrosis
Lung infection (hospital- or community-acquired pneumonia)
Gastrointestinal infections (abscesdperitonitis)
Kidney, bladder, and prostate infections (pyelonephritis/
perinephric abscess)
Systemic febrile syndromes
Cytomegalovirus infection
Febrile neutropenia
Brain abscess

The patient or the caregiver is trained in and

informed about the therapy to be carried out in the
home. The information has to be oral and in writing
and the pharmacist and the nurse can provide it.
The patient goes home and therapy begins.

One option to facilitate the coordination among the different steps is periodic meetings to discuss the cases with
the participation of all the members of the home care team.

F ~NTERVEN~IO~S
Home Parenteral Antibiotics
In general, all types of infection and all organisms are
susceptible to home IV antibiotic therapy. The treatment
of patients with bone and joint infections has proven
highly effective and is now well accepted.[211Other bacterial infections that have been studied extensively are
skin and soft tissue infections and lung infections. The
reason is that these infections fulfill two important
criteria: patients are clinically stable and require prolonged IV antibiotic therapy (>7 days).[221But home care
can be extended to great number of infections: bacterial,
viral, and fungal (Table 1). The patient's admission to
home care should be considered from the beginning of the
infection or should be wait until the patient is clinically
stable, depending on the infection.
A large number of cost-effectiveness studies have been
carried out (Table 2), all with positive results.

The maintenance therapies of opportunistic disease in

acquired immune deficiency syndrome (AIDS) are an-

Table 2 Studies of cost savings from home IV antibiotic therap)

study

Antoniskis A 1978[3s1
Stiver 1978[391
Kind 1979'401
Swenson 1981["I

20
23
15
8

Poretz 1982[421
Stiver 1982[431
Rehm 1983["]
Kind 1985[451
Corby 1986[")
Chamberlain 1988["'
Kane 1988[4s1
Tice 1991[491
Williams 1993'501
Williams 1994"']
Clopes 1998[291

150
95
48
315
36
6
27
290
56
58
13

Infection
NA
NA
NA
Osteomyelitis, pyelonephritis
and others
Osteomyelitis
NA
Bone and joint infections
NA
NA
Osteomyelitis
Cystic fibrosis
Osteomyelitis
Cellulitis. osteomyelitis
and others
Pneumonia
Several

Average savingsldayl
patient ($)

Average savingsldayl
patient (Euros)

165
97
95
148

196
115
113
176

142
135
305
350
345
265
618
303
262

169
160
362
416
410
316
735
360
3 12

252
152

300
180

Home Care Pharmacy Practice (Spain)

442

Table 3 Opportunistic disease in AIDS candidates for

home care
Infection
Cytomegalovirus infection

Acyclovir-resistant
Herpes simplex
Acyclovir-resistant
Herpes zoster
Pneumocystis carinii
pneumonia
Cryptococcosis
Histoplasmosis
Coccidiomycosis
Drug-resistant
mycobacterium
Pneumonia

Antimicrobial therapy
Maintenance and
induction therapies:
Ganciclovir IV
Foscarnet
Cidofovir
Foscarnet
Foscarnet
Pentamidine IV
Pentamidine aerosol
Amphotericin B
Amphotericin B
Amphotericin B
Amikacin

givers receiving hospital-at-home care reported greater

satisfaction than those in the hospital group.
One of the fundamental pharmacological treatments in
this group of patients is the opioid continuous infusion
with devices adapted to outpatient treatments as patientcontrolled analgesia pump.

The administration of chemotherapy at home has demonstrated that it is feasible and that it produces a decrease of
adverse effects and an improvement of the quality of life
and a monetary savings.i251
However, home care can also give support to the
patient with cancer in other areas: parenteral antibiotics
in febrile neutropenia, nutrition and fluid support, or
pain support.

3rd Generation Cephalosporins

Aminoglycosides

tibiotic therapy candidates for home care. The reasons are

that the patient is clinically stable and requires long-term
therapy. In some cases the induction can also be
considered to be treated at home. These infections and
treatments are described in Table 3.
Other support therapies for AIDS patients that can be
given at home are nutrition support, parenteral and
enteral, IV immunoglobulins, chemotherapy in lymphoma
or Kaposi's sarcoma, and care of terminally ill patients.

ystic Fibrosis
The majority of antibiotics needed for the treatment of
infectious complications of cystic fibrosis have to be
administered intravenously for several weeks; until recently these treatments were given on an in-patient basis.
As the lung disease progresses, patients may require more
frequent hospitalizations. This greatly increases health
care costs and adversely affects the patient's quality of
Home intravenous therapy in cystic fibrosis may also
cut costs by avoiding hospital admissions and may
improve family life and psychological well-being.

alliative Care
Some trials have evaluated the effectiveness of hospital at
home for terminally ill patient^.'^''^^] Patients and care-

In the support of hematology patients, the therapy candidates for home care may be chemotherapy, IV antibiotics in febrile neutropenia, blood products, IV immunoglobulins, fluid/electrolyte replacement, central line
maintenance, and specific treatments such as deferoxamine administration.
In the support of hematopoietic stem cell transplantation
there are programs developed to permit treatment with
chemotherapy at home and treatment of complications.[261

In cardiology patients some home-based interventions

have been published on the treatment of heart failure
patients and heart transplant patients. In our center
we also have experience with patients with pulmonary hypertension.
Increased survival of cardiovascular disease has resulted in a significant rise in the number of patients with
chronic, refractory heart failure requiring intensive medical management and follow-up. In a controlled
among a cohort of high-risk patients with congestive heart
failure, beneficial effects of a postdischarge home-based
intervention were sustained for at least 18 months, with a
significant reduction in unplanned readmissions, total
hospital stay. hospital-based costs, and mortality.
Cardiac patients receiving inotropic therapy can be
successfully treated in the home using specific admission
criteria and monitoring guidelines,'2s1 and home dobutamine infusions can improve functional status and quality
of life of patients with severe heart failure.

Home Care Pharmacy Practice (Spain)

Home care can also give support to heart transplant

patients. In our center we have the experience of a
program for organ rejection therapy, antilymphocyte
immunoglobulin, and high dosage of methylprednisolone
at home. After the experience, we can say that it is
feasible to carry out this treatment at home and the
satisfaction of the patients is high.[291
There are experiences of ambulatory treatment of
patients with pulmonary hypertension, with inhaled nitric
oxide and with prostaglandins, in both cases using an
ambulatory delivery system. In our center we have an
outpatient treatment program of pulmonary hypertension
with inhaled iloprost leading in some patients to
significant improvement in pulmonary hypertension and
in the quality of life with no adverse effects.

Nutrition

or%

The candidates for home nutrition support should be

clinically stable patients that require enteral or parenteral
nutrition for a long term. Before initiation of home
nutrition support, a nutrition assessment and a care plan
should be performed and after initiation nutrition status
should be monitored on a regular basis.[301
The indications included in a study of incidence of
home nutrition support made by the American Society for
Parenteral and Enteral Nutrition were:
Pareteral nutrition:
0
Short bowel disease.
e
Crohns disease and ulcerative colitis.
m
Gastric or duodenal fistula.
.S
Radiotherapy damage.
e
Congenital disorders.
e
Disorder of the GI motility.
Enteral nutrition:
0
Neuromuscular diseases:
Amyotrophic lateral sclerosis
Myasthenia gravis
Parkinsons disease
Alzheimers disease
Cerebral palsy
Cerebral vascular accident
Brain tumors
9
Oral and GI diseases:
Secondary to surgical procedure:
Head and neck
Esophagus or stomach
Malabsorption
Disorder of GI motility
Crohns disease and ulcerative colitis

443

Home care in elderly patients can help with the geriatric

assessment of disability and functional status and the
prevention of complications related or not related to
drugs. Stuck et al. conducted a three-year, randomized,
controlled trial of the effect of annual in-home comprehensive geriatric assessment and follow-up for people
who were 75 years of age or older.[311The results showed
that this intervention can delay the development of disability and can reduce permanent nursing home stays
among elderly people living at home.

Some programs of home care have been applied to

pediatric patients. Home care for cystic fibrosis and oncology patients is previously described. Other examples of
home care programs in children are patients with asthma
that require high technology at home,r321children with
newly diagnosed diabetes,[331and infants who require
neonatal special care and a family support program.[341

ery an

etrk

ts

Because of developments in surgery, early discharge after

surgery is becoming popular. These programs sometimes
need support at home, for example, with rehabilitation.[35.361In obstetric patients there have been experiences of home care giving support to the woman before or
after childbirth.[371

ers
Other home care programs with smaller pharmacist
implications are long-term mechanical ventilation and
renal dialysis.

The pharmacists role in home care should include the

following functions:
Development of protocols or practice guidelines for
each diagnosis candidate for inclusion in the home
care program in collaboration with other home care
team members.
Preadmission assessment. The pharmacist. together with the other team members, should assess

444

Home Care Pharmacy Practice (Spain)

3.

4.

5.

6.

the patients suitability for home care on the basis

of criteria described in the protocol (home
environment, psychosocial factors, and clinical
condition).
Coordination of preparation and delivery of drugs
to the patient or caregiver. Together with the medication, the pharmacist should provide the ancillary supplies and drug delivery systems. The pharmacist should also ensure appropriate disposal of
cytotoxic products.
Planning home treatment and care, also with an
interdisciplinary approach, involving the patient
and in collaboration with other team members. This
home treatment and care plan should be reviewed
and updated periodically and outcome should be
assessed.
Therapy monitoring using parameters previously
defined in the protocol. The pharmacist should carry
out this monitoring from the medical records and
verbal exchange with the patient and/or the caregiver, nurse, physician, and other family members.
Patient and caregiver education about the treatment.
The information should be both oral and written and
include:
e

Description of the therapy (drug, dose, route

of administration).
Goal of the therapy.
Administration technique.
Special precautions regarding storage, handling, and disposal of drugs.
Emergency procedure.

11. Participation in performance improvement activities. Patient satisfaction and outcome should be
monitored to detect and resolve problems. Quality
of life should also be considered.

news/newslettershomecare/index.html.
e

7. Information for home care team members regarding:

Drug stability and compatibility.

Adverse effects.
Administration technique.

8. Early detection and reporting of adverse drug

effects.
9. Monitoring pharmacokinetic laboratory data for
evaluation of efficacy and prevention of adverse
effects of the specific drugs (vancomicyn, aminoglycosides, cyclosporin, etc.).
10. Selection of drug delivery systems for parenteral
and inhaled drugs. This selection should be carried
out in cooperation with the physician and nurse
taking into account safety features, ease in handling, and cost. It should be individualized according to the patients characteristics.

Section of Home Care Practitioners of American

Society of Health-System Pharmacists (ASHP)(USA):
www. ashp.orghomecare.
Home Care Highlights of American Society of HealthSystem Pharmacists (USA): www.ashp.org/public/
ASHP Guidelines (USA): www.ashp.org/bestpractices.
American Society of Parenteral and Enteral Nutrition
(with the Standards of Practice for Home Nutrition
Support)(USA) : www. clinnutr .org .
Joint Comission on Accreditation of Healthcare Organizations (USA): www.jcaho.org.
American Academy of Hospice and Palliative Medicina (USA): www.aahpm.org.
Edmonton Palliative Care Program (Canada): www.
palliative.org.
National Council for Hospice and Specialist Palliative
Care Services (United Kingdom): www.hospice-spccouncil,org.uk.
Agence Nationale dAccreditation dEvaluation en
Sante, France (with the recommendations for the
medical records of the home care patients for ambulatory nursing professionals) (France): www.anaes.fr.
American College of Chest Physicians (ACCP) (Patient
Education Guides: Mechanical Ventilation at Home)
(USA): www.chestnet.org/health.science.policy.

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C. Home intravenous antibiotics for cystic fibrosis (Protocol for a Cochrane Review). In The Cochrane Library,
Issue 3; Update Software: Oxford. 2000.
Grande, G.E.; Todd. C.J.; Barclay, S.I.; Farquhar, M.C.
Does hospital at home for palliative care facilitate death at
home? Randomised controlled trial. BMJ 1999, 319,
1472- 1475.
Holdsworth, M.T.; Raisch, D.W.; Chavez, C.M.; Duncan,
M.H.; Parasuraman, T.V.; Cox, F.M. Economic impact
with home delivery of chemotherapy to pediatric oncology
patients. Ann. Pharmacother. 1997, 31; 140- 148.
Herrmann, R.P.; Leather, M.; Leather, H.L.; Leen, K.
Clinical care for patients receiving autologous hematopoietic stem cell transplantation in the home setting. Oncol.
Nurs. Forum 1998, 25, 1427- 1432.
Stewart, S . ; Vandenbroek, A.J.; Pearson, S.; Horowitz, J.D.
Prolonged beneficila effects of a home-based intervention
on unplanned readmissions and mortality among patients
with congestive heart failure. Arch. Intern. Med. 1999,
159. 257-261.
Mayes, J.; Carter, C.; Adams, J.E. Inotropic therapy in the
home care setting: Criteria, management and implications.
J. Intraven. Nurs. 1995, 18. 301-306.
Clopes, A. Hospitalizacidn Domiciliaria: Participacidn
del Sewicio de Farmacia; Reuniiin Internacional Farmacia
Clinica y Atencion FarmacCutica: Barcelona. Spain. June
4-6, 1998.
American Society for Parenteral and Enteral Nutrition
(ASPEN). Standars of practice for home nutrition support.
NCP 1999; 14; 151-162.
Alessi, C.A.: Bula,
Stuck, A.E.; Aronow, H.U.; Steiner, A,;
C.J.; Gold, M.N.; Yuhas, K.E.; Nisenbaum, R.: Rubenstein, L.Z.; Beck, J.C. A trial of annual in-home comprehensive geriatric assessments for elderly people living
in the community. N. Engl. J. Med. 1995, 333: 11841189.
Ryan, C.A.; Willan, A.R.; Wherrett. B.A. Home nebulizers
in childhood asthma. Clin. Pediatr. 1988. 27. 420-424.
Dougherty, G.E.; Soderstrom, L.: Schiffrin. A. An economic evaluation of home care for children with newly
diagnosed diabetes: Results from a randomized controlled
trial. Med. Care 1998, 36. 586-598.
Rieger, I.D.; Henderson-Smart. D.J. A neonatal early
discharge and home support programme: Shifting care
into the community. J. Pediatr. Child Health 1995, 31,
33-37.
Worland, R.L.; Arredondo. J.; Angles. F.; Lopez-Jimenez,
F.; Jessup. D.E. Home continous passive motion machine
versus professional physical therapy following total knee
replacement. J. Arthroplast. 1998, 13, 784-787.
Donald, I.P.: Baldwin, R.N.; Bannerjee. M. Gloucester
hospital-at-home: A randomized controlled trial. Age
Ageing 1995, 24; 434-439.

446

37. Brooten, D.; Mnapp, FT.; Borucki, L.; Jacobsen, B.: Finkler,
S . ; Arnold, L.; Mennuti, M. Early dischargc and home care
after unplanned cesarean birth: Nursing care time. J .
Obstet. Gynaecol. Neonat. Nurs. 1996, 2.7, 595 --600.
38. Antoniskis, A,; Anderson, B.C.; Van Volkinburg, E.J.;
Jackson, J.M.: Gilbert, D.N. Feasibility of outpatient selfadministration of parenteral antibiotics. West J. Med.
1978, 128, 203-206.
39. Stiver, H.G.; Telford, G.O.; Mossey, J.M. Intravenous
antibiotic therapy at home. Ann. Intern. Med. 1978, 89,
690 693.
40. Kind, A.C.; Williams, D.N.; Persons, G.; Gibson, J.A.
Intravenous antibiotic therapy at home. Arch. Intern. Med.
1979, 139. 413 415.
41. Swenson, J.P. Training patients to administer intravenous
antibiotics at home. Am. I . Hosp. Pharm. 1981, 38, 14801483.
42. Poretz, D.M.: Eron, I,.J.; Goldenberg, R.I. Intravenous
antibiotic therapy i n an outpatient setting. JAMA, J. Am.
Med. Assoc. 1982, 248, 336-339.
43. Stiver, M.C.; Trosky, S.K.; Cote, D.D.; Oruck. J.L. Selfadministration of intravenous antibiotics: An efficient,
cost-effective home care program. J. Can. Med. Assoc.
1982. 127, 207-211.
44. Rchni, S.J.; Weinstein, A.J. Home intravenous antibiotic

ome Care Pharmacy Practice (Spain)

45.

46.
47.

48.

49.

50.

therapy: A team approach. Ann. Intern. Med. 1983, 99,

388-392.
Kind, A.C.; Williams, D.N.; Gibson, I . Outpatient intravenous antibiotic therapy: Ten years experience. Postgrad.
Mcd. 1985, 77, 105-111.
Corby, D.; Schad, R.F.; Fudge, J.P. Intravenous antibiotic
therapy: Hospital to home. Nurs. Manage. 1986,17, 52 -61.
Chamberlain, T.M.; Lehman, M.E.; Groh, M.J.; Munroe.
W.P.; Reinders, T.P. Cost analysis of a home intravenous
antibiotic program. Am. J. Hosp. Pharm. 1988, 45, 23412345.
Kane, R.E.; Jennison, K.; Wood, C.; Black, P.G.; Herbst,
J.J. Cost savings and economic considerations using home
intravenous antibiotic therapy for cystic fibrosis patients.
Pediatr. Pulmonol. 1988, 4. 84-89.
Tice, A.D. An office model of outpatient parenteral
antibiotic therapy. Rev. Infect. Dis. 1991. 13 (S2), 184188.
Williams, D.N.; Bosch, D.; Boots, J.; Sehneider, J. Safety,
efficacy, and cost savings in an outpatient intravenous
antibiotic program. Clin. Ther. 1993, 15, 169 179.
Williams, D.N. Reducing costs and hospital stay for
pneumonia with home computerized cefotaxime treatment
results with a computerized ambulatory drug delivery
system. Am. J. Mcd. 1994, 97 (2A), 50-55.
~

51.

PHARMACY PRACTICE ISSUES

Arthur C. Lipman
University of Utah, Salt Lake City, Utah, U.S.A.

Hospice programs have existed in the United States for

more than 25 years, providing symptom control-based
palliative care for patients with advanced, life-limiting
disease. In fact, more than 3000 hospice programs are
now operating or are in formation in the United States.
The World Health Organization (WHO) defines and
comments on palliative care as follows: Palliative care
is active total care of patients whose disease is not responsive to curative treatment. Control of pain, of other
symptoms, and of psychological, social and spiritual
problems is paramount. The goal of palliative care is
achievement of the best possible quality of life for patients and their families.[11 Pharmacists often serve as
key members of hospice interdisciplinary teams. and
many opportunities for pharmacists to provide valuable
clinical services exist in hospice programs. Most hospice
care is provided in the patients homes. Palliative care
units are increasingly being integrated into hospitals and
long-term care facilities.

The explosive growth of interdisciplinary hospice and

palliative care programs for patients with terminal
illnesses has created excellent opportunities for pharmaceutical care. In the United States, the number of
hospice programs has grown from 1 less than 30 years
ago to approximately 3000 today. The importance of
pharmacists providing care to terminally ill patients
appeared in the American pharmaceutical literature over
25 years ago.[21In addition, rapidly expanding opportunities for pharmacists in hospice care were defined in the
1 9 9 0 ~ . [ All
~ pharmacists should know about the availability and quality of hospice care in their communities,
and should be able to refer patients to programs appropriate for their needs.
In the 1970s and 1980s, hospices provided care
primarily for patients with advanced cancer. Today,
hospice care is common for patients with cancer; acquired
Encyclopedia of Clinical Pharmacy
DOI: 10.1081E-ECP 120006340
Copyright 0 2003 by Marcel Dekker, Inc. All rights reserved

immunodeficiency syndrome (AIDS); degenerative neurological diseases, such as multiple sclerosis and amyotrophic lateral sclerosis; end-stage organ system failure,
including congestive heart failure, hepatic disease, pulmonary disease, and renal disease; and patients with dementia and other progressive, irreversible disorders.
The word hospice is derived from a medieval
French term for resting places established for Crusaders
on their journeys to the Holy Land. It was revived in the
last century by a Catholic order that provided resting
places for terminally ill patients in Ireland and England.
By the mid-l900s, several such hospice programs existed
in the United Kingdom. However, the modern hospice
movement based on comprehensive symptom control only
began in 1967, with the opening of St. Christophers
Hospice in London. The first American hospiceoriginally called simply Hospice, Inc., now The Connecticut Hospice-was
started in the early 1970s in New
Haven, CT. That program became the National Cancer
Institute Demonstration Project of Hospice Care from
1974 to 1977. More than 1000 American pharmacists are
now estimated to provide hospice pharmaceutical care as
integral parts of their practices. Many more are needed.
A hospice is a program of care, not necessarily a
facility, per se. In the United States, most hospice care is
provided in patients homes. Some dedicated inpatient
hospice facilities exist, as do hospice wings of long-term
care facilities and hospice beds in hospitals. These
inpatient hospices commonly provide support for the
home care programs, respite care (admission of patients
to allow their families to rest so that they can resume
home care), admissions for difficult symptom control
problems, and admissions for care in the last hours or
days, when necessary.
The term palliative care was used initially to define
the provision of symptom relief for patients who were no
longer considered to be candidates for cure or remission.
Today, the need for palliative care throughout the course
of life-threatening disease, including patients for whom
cure will be achieved, is becoming more widely accepted.
Palliative medicine is a recognized medical specialty in
the United Kingdom and several other countries. In 1997,
447

448

Hospice and Palliative Care

the report of the Committee on Care at the End of Life of

the Institute of Medicine of the National Academy of
Sciences concluded that palliative care should become,
if not a medical specialty, at least a defined area of
expertise, education and research. [41 Hospice and
palliative care are often used interchangeably.
Hospices provide care for patients with advanced,
irreversible disease and a life expectancy measurable in
weeks to months as opposed to years. The defined unit of
care is the patient and their family. The focus of care
spans physical, psychological, social, and spiritual domains. This requires an interdisciplinary team. Nurses
usually coordinate home visits and serve as team leaders.
The patients primary care physician normally continues
to provide care, often in consultation with the hospice
medical director. Other key members of the team are

social workers, nursing assistantslhome health aides,

chaplains, volunteers, and pharmacists. Persons from several other disciplines support the hospice team (Fig. 1).
As shown in Fig. 1, the central focus of care is the
patient, family, and primary care person(s), who is usually
a family member. They continue to work with their
primary physician. The interdisciplinary hospice team
listed in the next concentric circle from the center provides direct support. This team may include both health
care professionals and other persons who are equipped to
deal with issues that are complicating the lives of the
patientdfamilies (e.g., financial counselors). The third
concentric circle from the center includes persons who
support the team. Pharmacists have both direct patient
care and supportive roles in hospice teams as described in
the following paragraphs.

PATI ENT/FAM ILY

SUPPORT SYSTEM
PUBLIC INFORMAT ION

Fig. 1 The hospice interdisciplinary team. The patient, primary caregiver, and family are the focus of the hospice teams efforts in
collaboration with the patients primary physician. The core team is represented by the next circle away from the center. The support
team is indicated by the outer circle. Community resources that support hospice care are listed outside that circle. Pharmacists serve on
both the core team (second circle from the center) by providing direct pharmaceutical care to patients and families, and on the support
level (next circle out from the center) by providing professional and public education about drug therapy in the care of terminally ill
patients. (From Lipman AG, Berry JI. Pharmaceutical care of terminally ill patients. Journal ofPharmaceuticaZ Care Pain and Symptom
Control, 1996; 3(2):31-56.)

Hospice and Palliative Care

There is a need for elimination of artificial barriers

between the time when a cure is sought and the
inevitability of death is accepted. This barrier exists, at
least in part, due to the requirement for documenting life
expectancy by the Medicare Hospice Benefit. The U.S.
Congress defined this benefit in the 1980s through which
Medicare beneficiaries can assign their medicare part B
benefits to any Medicare-certified hospice program. That
program then receives a daily fee from Medicare in return
for assuming responsibility for the patients total care,
including drugs and pharmaceutical care. To be eligible
for this benefit, the patients physician must certify a
probable life expectancy of 6 months or less. This arbitrary
time limit has created psychological barriers for physicians, patients, and their families, resulting in many patients not being referred, seeking, or receiving the hospice
care to which they are entitled. Because pharmacists commonly have long-standing relationships with families they
serve and enjoy their patients trust, pharmacists are often
in the best position to advise patients about the importance
of developing relationships with a hospice program as
soon as possible after determination that the disease has
a probability of being life ending.
Hospice and palliative care are becoming much more
widely recognized by healthcare providers. The American
Academy of Hospice and Palliative Medicine (founded in
1988 as the Academy of Hospice Physicians) and the
Association of Hospice Nurses are respected national
organizations of health care professionals who provide
palliative care. The National Hospice and Palliative Care
Organization (NHPCO, formerly known as the National
Hospice Organization [NHO]) includes the National
Council of Hospice Professionals (NCHP). The 15 membership sections of the NCHP include an active pharmacist section.

449

often in an excellent position to recommend hospice care

and to refer families to appropriate programs.
Services provided by pharmacists in American hospices have only been qualitatively and quantitatively
documented twice, in 1979r51and 1991.[61Many more
pharmacists provide these services today than when the
latter survey was completed, but the observed types and
mix of services do not appear to have changed much since
the 1990s.
Although many pharmacists serve as hospice volunteers, about three-fourths are paid for their services. The
majority of pharmacists who provide services to hospice
programs are not employed directly by the hospices, but
by a provider of pharmaceutical services such as a home
health pharmacy or hospital. Many are employees of
pharmacies that have contracts with hospices to provide
drugs and services. In recent years, specialized hospice
pharmacy service providers have been developed in
several parts of the United States.
The 1991 surveyL6 reported that dispensing fees
accounted for about one-half of the reimbursement
received by pharmacists. In the past few years, payment
for cognitive services has become more common. Some
pharmacists provide only consulting or dispensing services, but many provide drug products, home health
supplies and equipment, and pharmaceutical care. Pharmaceutical services other than prescription dispensing
services are not usually required by licensing or certifying agencies. Payment for cognitive services is at
the discretion of the hospice administration. The experience of many hospices has been that integration of
pharmacists directly into planning and provision of patient care both improves the quality of symptom control
and lowers costs. In many hospices, pharmacists are now
active participants in weekly or biweekly interdisciplinary team (IDT) meetings at which patients progress is
discussed and care plans are refined.

UTI

It is unfortunate that many physicians and families remain

unaware of the benefits that modern hospice care
provides. As a result, referrals to hospice programs often
do not occur, or occur when the patient has only days to
live. Hospice care is most efficacious and cost effective
when referrals are made early, while the patient still has
months to live and is reasonably active. Relationships
between the hospice team and the patient/family that are
established before crises occur are most effective. Such
relatively early relationships permit the hospice team to
provide more effective and efficient care when it is
actively needed. As the most accessible and trusted
healthcare professionals (Gallup surveys), pharmacists are

H
Most pharmacists possess many of the skills needed to
provide pharmaceutical care to terminally ill patients. In
the last few years, pharmacy curricula have placed increased emphasis on pain management and symptom
control.
Many pharmacists increase their knowledge of drugs
and dosing regimens for symptom control in seriously ill
patients through consultation and visits with experienced
hospice pharmacists. Pharmacists can gain a valuable
perspective on hospice care by taking hospice volunteer
training. Continuing pharmaceutical education directly

450

Hospice and Palliative Care

Table 1 Selected palliative care resources

Journals
Journal of Pain and Palliative Care Pharmacotherapy (incorporating the former Journal of Pharmaceutical Care in Pain and Symptom
Control and The Hospice Journal)
Pharmaceutical Products Press, an imprint of The Haworth Press, 10 Alice Street, Binghamton, New York; (800) HAWORTH;
e-mail: [email protected]
Journal of Pain and Synzptom Management
Elsevier Science, Inc.; (888) 437-4636
Pain
Journal of the International Association for the Study of Pain (IASP); (206) 547-6409
The Journal of Pain
Official Journal of the American Pain Society; (800) 654-2452; e-mail: [email protected]

Newsletters
IASP (International Association for the Study of Pain) Newsletter
(206) 547-6409
American Pain Society Bulletin
American Pain Society; (847) 375-4715; e-mail: [email protected]

Texts
Berger AM. Portenoy RK, Weissman DE. Principles and Practice of Supportive Oncology. Philadelphia, Lippincott-Raven, 1998.
Doyle D, Hanks GWC, MacDonald N, editors. Oxford Textbook of Palliative Medicine, 2nd edition. New York and Oxford,
Oxford University Press, 1997. Berger AM, Portenoy RK, Weissman DE. Principles and Practice of Supportive Oizcology, 2nd Ed.;
Philadelphia, Lippincott-Raven. in press 2002.
Web sites
National Hospice and Palliative Care Organization
www.nho.org
PDQ (Physician Data Query)

[email protected]/
Talarian Map Cancer Pain
www stat.washington.edulTALARIAiTALARIA.htm1
Open Society Institute: Project Death in America

www.cyberspy.com/-websterldeath.htm1
The Palliative Medicine Program
www.mcw.edu/pallmed
Hospice Foundation of America
www.hospice foundation.org
Information about hopsice with links
www.hopsiceweb.com
Hospice Hands web site
http://hospice-cares.com
Purdue Pharma Pain and Palliative Care Information
http://www .partnersagainstpain.com
Additional web references can be found in Ref. [9].

451

Hospice and Palliative Care

relevant to hospice care and symptom control is often

provided at meetings of the American Society of Consultant Pharmacists, American Society of Health-System
(previously Hospital) Pharmacists, American Pharmaceutical Association, the National Hospice and Palliative
Care Organization, and at some state and local professional associations. Several journals, newsletters, and web
sites focus on pain and symptom control. Examples are
listed in Table 1. Because hospice care is interdisciplinary
by definition, most programs are open to suggestions of
additional ways in which any discipline can contribute to
the programs overall objectives.
Hospice programs are always recruiting and training
new volunteers. Therefore, most readily welcome calls
from persons in the community interested in learning
more about the program or becoming involved in patient
care. Any pharmacist can simply call a local hospice and
make an appointment to meet with the staff to discuss
unmet pharmaceutical care needs. These include a range
of activities, including administrative responsibilities,
provision of medications, and outcome-oriented pharmaceutical care.
Common administrative functions include the following:
Managing program or facility (if applicable)
Serving on the hospice board or professional advisory
committee
Negotiating contracts with provider pharmacies
Reviewing and ensuring compliance with state and
federal laws and regulations that relate to the provision
of hospice pharmaceutical care and services
Developing drug-related policies and procedures
Participating in continuous quality improvement and
quality assurance activities, including drug-use evaluations and cost-avoidance and cost-effectiveness
studies
Procuring medications for indigent patients through
pharmaceutical industry patient assistance programs
Managing the hospice formulary
Common clinical functions include the following:
Developing pharmaceutical care plans, including
assessment and monitoring for therapeutic and toxic
outcomes
Participating in hospice interdisciplinary team meetings (chart sounds)
Performing drug regimen reviews
Providing pain and symptom management consultations to team members and to patients primary
physicians

Preparing routine admission orders

Developing drug-use protocols
Making home visits as needed to assess medication
needs and use, and to educate patientdfamilies about
medication use
Common educational functions include:
Providing staff education in drug therapy for symptom
control and other indications
Providing education to patients and their families on
medication use
Providing physician education to hospice patient
primary physicians
Providing public education on drug use in terminal
care
Educating hospice volunteers about desired and
achievable outcomes from medication use
Providing clerkships for pharmacy students
Common dispensing functions include the following:
Dispensing prescription and over-the-counter medications, including therapeutic interchange
Providing for delivery of medications to patients
homes
Extemporaneous compounding of dosage forms that
are not commercially available
Providing home infusion service
Maintaining patient medication profiles

The broad range of relevant pharmaceutical services

needed by a progressive hospice program nearly always
requires more than one provider. Simple. informal needs
assessments of programs with which pharmacists want to
affiliate is an effective way to market their services.
Hospice Medicare payments and most other insurance
reimbursement is capitated (i.e., a flat daily fee is paid to
the program for all aspects of care). Therefore, the full
range of care must be provided within a defined cost
structure. Efficient formulary management, including
generic and therapeutic interchange and elimination of
unneeded drug therapy, can improve both patient care and
the fiscal health of the program. Patient and family
satisfaction are also important considerations for every
hospice program. Medication-related education provided
by a pharmacist can markedly increase satisfaction.
Hospice nurses often work relatively independently from

452

their patients physicians. Therefore, by providing nursing

education and consultation about patient assessment for
responses to therapy and about drug use, pharmacists can
increase their perceived need on the hospice team.

Most hospice referrals come to the programs from

patients primary physicians. Some come directly from
families who have heard about hospice from other
families that used the service or from presentations made
in the community. Most hospice programs send a nurse to
the paticnts home (hospital or nursing home) to assess
thc patient and to perform an intake evaluation. This
cvaluation requires a detailed history, including a
medication history.
Pharmacists need to know patients' prescription and
nonprescription medication intake; use of nutritional
supplements that may be pharmacologically active,
physical, and psychiatric diagnoses; and relevant laboratory test data when they are available. Usually, that
information is available from the primary physicians
referral and the documentation from the intake interview.
Frequently, laboratory test data arc not available because
of the hospice philosophy of only doing tests that will
directly affect paticnt outcomes. Renal function oftcn can
be estimated from the quantity and quality of thc patients
urinary output balanced against intake. Careful dose
titration is often needed in the absence of laboratory test
data as patients metabolic and elimination capabilities
decline. Sometimes, pharmacists make home visits to get
morc complete medication histories, and to ascertain the
familys understanding of medications and ability to
administer them correctly.

Most pharmacists will interact with terminally ill patients

or their family members at soinc time. Many pharmacists

Hospice and Palliative Care

will provide services to dying patients and hospice

programs. An increasing number of pharmacists will
work with hospice programs as a substantial part of
thcir practices.
Effective management of pain and othcr symptoms
associated with life-threatening disease is usually
attainable with the proper combination of pharmacological and nonpharmacological interventions. Pharmacists can, and should, play an important role in
ensuring that their patients receive this care when it
is needed.

EF
1. WHO Expert Committee. Cancer Pain and Palliative
Care; Technical Report Series, World Health Organization: Geneva, 1990; Vol. 804.
2. Lipman, A.G. Drug therapy for terminally ill patients. Am.
J. Hosp. Pharm. 1975, 32. 270-276.
3. Arter, S.G.; Lipman, A.G. Hospice care; a new opportunity
for pharmacists. J. Pharm. Pract. 1990, 3, 28-33.
4. Approaching Death: Improving Care at thi, End of Lije;
Field, M.J., Casell, C.K., Eds.; National Academy Press:
Washington, 1 997.
5. Berry, J.I.; Pulliam, C.C.; Caiola, S.M.; Eckel, F.M.
Pharmaceutical services in hospices. Am. J. Hosp. Pharm.
1981. 38, 1010 1014.
6. Arter, S.G.; Berry, J.1. The provision of pharmaceutical
care to hospice patient: Results of the national hospice
pharmacist survey. J. Pharm. Care Pain Symptom Control
1993, I (I), 25-42.
7. Lipman, A.G. Cumculum on pain for pharmacy students.
IASP Newsl. 1992 MayIJune, 2 ~ 4 .
8. Jacox, A.; Carr, D.B.; Payne, I<., et al. Management of
Cancer Pciin, Clinical Practice Guideline. AHCPR
Publication Number 94-0592, Rockville, MD. Agency
for Health Care Policy and Rescarch; U.S. Department of
~

Health and Human Services, Public Health Service,

1994.
9. Gavrin, J.R.An annotated guide to pain and palliative care
on the World Wide Web. J. Pain Palliat. Care Pharmacotherap. 2002, I 6 (2), 37 48.

PHAKMACY P KACTICE I SSU ES

ic

ai

Joaquin Ciraldez
Ana Ortega
Antonio ldoate
Azucena Aldaz
Carlos Lacasa
Clinica Universitaria de Navarra, Parnplona, Spain

INTRODUCTION
Hospital pharmacy service refers to the pharmacy that
is inside a hospital to serve inpatients and outpatients who
receive care in the hospital or require drugs that are only
delivered in hospitals. Hospital pharmacy practice
makes reference to all activities carried out by hospital
pharmacy service personnel to serve those patients.
In Spain, by law, there must be a hospital pharmacy
service in every hospital with 100 beds or more.] This
service must be under the supervision of a hospital
pharmacist. The total number of pharmacists depends on
different factors such as number of beds, services
provided to patients, and type of hospital. All hospital
pharmacists working in the service must be hospital
pharmacy specialists.
Activities common to all hospital pharmacy services in
Spain are pharmacy management, dispensing of drugs,
drug information, and drug manufacture. Many other
activities are also conducted in many hospital pharmacies
such as centralized parenteral admixture preparation,
design and preparation of parenteral and enteral nutrition
as well as follow-up of patients under this kind of
nutrition, therapeutic drug monitoring, pharmacoeconomics, drug surveillance, research, activities related to
medical devices, radiopharmaceutical activities, clinical
pharmacy activities, pharmaceutical care, participation in
committees, and so on.
In what follows, hospital pharmacy practice in Spain
will be described. As an introduction, a brief history and
description of the evolution of this discipline and the
Spanish hospital pharmacists training program will be
presented. Then, activities currently conducted by hospital pharmacy service personnel will be described and
clinical pharmacy opportunities will be indicated. And
finally, future trends will be outlined. Useful references
will be given throughout the report.
Encyclopedia of Clinical Pharmacy
DOI: 10.1081E-ECP 120006377
Copyright 0 2003 by Marcel Dekker, inc. All rights reserved

BRIEF HISTORY OF HOSPITAL

P H A ~ ~ A CINYSPAIN
Pharmacists have always worked with doctors and nurses,
in and outside hospitals, but it was not until 1955 that a
National Association of Pharmacists from Civil Hospitals
was created in Spain. In 1967, the Spanish Public Health
Service created its own hospital pharmacy services in
state hospitals. In 1977, hospital pharmacy services were
regulated as was the training of hospital pharmacists. In
1988 the name of the association changed to the Spanish
Society of Hospital Pharmacists, as it is known today.[311
In 1990, the Spanish Parliament approved the Medicine
Law ,I l l which consolidated hospital pharmacy services
as the basic structure for the rational use of drugs and
specified the residency program as the training needed to
work in those services.

Hospital pharmacy is a discipline in permanent transition.

In Fig. 1, activities conducted by hospital pharmacists as
well as the number of hospital pharmacists in Spain from
1955 are presented. Originally, hospital pharmacists were
responsible for management and delivery of stocks of
drugs to the wards. Since then the role of the pharmacist
has evolved to include a more rational dispensing system
(unit-dose delivery) and clinical activities and pharmaceutical care.
Hospital pharmacists in Spain, as in other countries,
are increasing their direct communication with patients,
nurses, and doctors and at the same time are transferring
some activities to others, such as drug manufacture to the
pharmaceutical industry. The therapeutic role of drugs is
increasing; furthermore, the responsibility of pharmacists
453

454

Hospital Pharmacy Practice in Spain

Quality management
1989- ADDlied research
Rational therapeutics
Coordination with primary care
Continued training
Etc.
1984.89

Clinical pharmacokinetics

00
1974-84
Committees
Team-work
Training
Drug information
Rational dispensin
1955 -74 Purchase
Manufacture
Control
Dispensing
Management

Number o f hospital

Fig. 1 Activities conducted by hospital pharmacists and the

number of hospital pharmacists in Spain since 1955.

goes beyond simple delivery of prescriptions. Clinical

pharmacy is appearing as a new culture for professional
practice. Clinical pharmacy can be defined as a compound
of beliefs, rules, and values that constitute the foundation
of the pharmacy practice, cooperation in the health care
team, and direct pharmacist interventions.[*] The objective is better patient care. Spanish health care organizations are incorporating this new role of the pharmacist in
different ways. An example is the addition of activities
involving direct contact with patients (clinical pharmacy
and pharmaceutical care) to the hospital pharmacist
training program.
Clinical pharmacy is founded on three basic activities:
drug selection, drug information, and rational distribution
(unit-dose). If these activities are not present, other
clinical activities cannot be developed. Drug information,
the unit-dose delivery system, parenteral and enteral nutrition programs, therapeutic drug monitoring, participation in clinical trials, and other activities developed by
Spanish hospital pharmacists are modest examples of
what is known as clinical pharmacy.[21Clinical pharmacy
is slowly changing society's idea of hospital pharmacy
in Spain.

is now four years. The reason for this extension is that

activities conducted by hospital pharmacists have increased considerably and training had to adapt to these
changes. Activities outside the pharmacy service and in
proximity to the patient and health care team are
necessary. In the fourth year, residents are supposed to
take their knowledge to the bedside and be with the
patient and health care team. They have to take responsibility for the pharmacotherapy given to each patient,
work as part of a team, and develop a critical ability to
solving all pharmacotherapeutic problems.[41 The residency program is regulated, practice-based, and can be
done only in certain accredited hospitals, and students
have to first pass a national exam.[32s361
Currently, approximately 100 pharmacists per year can be admitted to the
residency program, which includes all activities conducted in hospital pharmacy services.

CTlVlTlES CONDUCTE

Activities developed in a hospital pharmacy service can

be conducted either from inside the service or outside of
it. In the latter case, activities are obviously connected to
centralized activities.
In order to completely understand the situation in
Spain, it is important to know first how the Spanish health
system works. In Spain, there are public and private hospitals (around 795 hospitals; see Fig. 2).[301Every Spanish
person has the right to free public health care; however, if
patients prefer, they can go to a private hospital and pay
for the health care that they receive. In addition, some

V
In Spain, a hospital pharmacy training (residency) is
mandatory in order to work as a hospital pharmacist. This
specialization has been regulated by law since 1982.'3,291
Until 1999 the residency program lasted for three years; it

50

s b

Fig. 2 Number of hospitals per region in Spain (From

Ref. [30]).

Hospital Pharmacy Practice in Spain

private hospitals have agreements with the public sector

or with insurance companies.
In what follows, some activities conducted by Spanish
hospital pharmacists will be briefly described. Three activities are considered the foundation of hospital pharmacy in Spain: adequate drug selection, drug information, and drug delivery. Some Spanish references include
most of the activities developed at Spanish hospitals[73s1
as well as statistics on hospital activity."] Recommendations of the Spanish Society of Hospital Pharmacists
(SEFH) for some of the activities can be found at
www.sefh.es/normas/normasy.htm.
In addition, there are
now many possibilities for networking. The SEFH
facilitates interhospital communication and interest
groups have been created.13'I Some other international
organizations provide the same opportunities for their
specific topics (e.g., www.senpe.com/Gtrabaj/textos2.htm
for parenteral and enteral nutrition). Statistical data will
not be presented here but can be obtained from a survey
conducted by the SEFH in 1995;"01 more up-to-date
figures will become available from the year 2000 survey.

an

There are two important areas in management, clinical

and purchasing management. In every hospital pharmacy
service it is necessary to establish basic procedures for
drug selection, acquisition, reception, storage, and distribution with the least cost and risk for patients.
Clinical management refers to an efficient and safe use
of drugs according to pharmaceutical criteria. To achieve
this goal there are many possible courses of action; however, the most basic one, which is conducted in all Spanish hospital pharmacy services, is the definition of a
hospital-specific drug formulary that lists all the drugs
approved by the hospital's Pharmacy and Therapeutics
(P&T) committee. In Spain a hospital pharmacist is one
of the members of P&T committee, frequently the president or the secretary. The P&T committee has the following tasks: to select drugs; to recommend a drug use
policy; to educate about correct drug use; to set drug use
protocols and establish the means of ensuring compliance; to introduce a program for the detection, followup, and evaluation of adverse drug reactions; and to cooperate in a quality control program. Criteria used by the
P&T committee for drug selection are, in order of importance: efficacy, safety, cost-effectiveness, therapeutic
contribution, and incidence.
Regarding purchasing management, the main responsibility of the purchasing unit of a hospital pharmacy
service is to have available the necessary drugs to treat
hospital patients. Almost all purchasing units in Spanish

455

hospital pharmacies are computerized and all have the

following tasks: to define requested drugs. to establish
purchasing procedures according to Spanish law, to
place orders, to inform hospital directors of acquisitions,
and to develop a quality control program. Spanish references to management techniques are given in the

Drug dispensing/distribution is one of the main clinical

activities of Spanish hospital pharmacists. Many studies
have shown that the unit-dose distribution system has
reduced drug errors, and it is one of the main contributions of the hospital pharmacy['*] to patient care. Pharmacist participation in medical rounds and presence at the
time of prescription can result in even better patient care
and a prompter detection of treatment failures.[133141
Such
"clinical pharmacy" activity is being conducted with
some groups of patients in some Spanish h ~ s p i t a l s " ~and
'
is becoming more frequent.
Most Spanish hospitals have a unit-dose drug distribution system (Fig. 3). The main objectives of such a
system are the following: knowledge of patient pharmacotherapeutic profile, which encourages pharmacist intervention before drug dispensation and administration;
decrease of drug errors, interactions, and adverse reactions; reduction in treatment costs; decrease of drug manipulation by nurses on the wards; and billing or economic assignment according to each patient's real expenses.
In a unit-dose system, the pharmacy service delivers
drugs to be directly administered to the patient without
need of further intervention by others. In hospitals, the
distribution of some drugs (e.g., narcotics, compassionateuse drugs, research drugs, and drugs for emergencies)
requires a special control and distribution procedure.
Normally, these drugs are not sent with the rest of the
medication; and the procedure for these drugs will be
presented later on. The following is a description of the
unit-dose system as it is applied in most Spanish hospital
pharmacy services.
Medical orders are handwritten by doctors and a copy
is sent to the hospital pharmacy service, where it is recorded in the computer system. However, in some hospitals, doctors enter the medical order directly into the
computer; few proceed in this way at the moment but
the number is increasing. In a few hospitals, with some
types of patients, pharmacists are present at the time of
prescription. Prescriptions may specify generic or brand
names depending on the hospital's policy, and pharmacists can choose bioequivalent drugs depending on what
is available.

456

Hospital Pharmacy Practice in Spain

Fig. 3 Unit-dose area in a Spanish hospital pharmacy service.

Medical orders are checked by pharmacists. and doctors or nurses are consulted if necessary. At this point,
pharmacists have a good opportunity for intervention. To
prove the appropriateness of the prescription for a specific
patient, patient data must be checked. The unit-dose
system is computerized in all hospital pharmacies. Computer programs may be in-house or standard. Some
information can be checked on the computer; in some
cases programs even make suggestions.[16 Subsequently,
lists are created for auxiliary personnel to prepare the
delivery trolleys to take the medications to the wards. In
a few hospitals, for some specific units, automated delivery (e.g., PyxisE, Suremed, OmnicellT~)
is used. In
this case, pharmacists, or someone under their supervision, have to check the accuracy of the delivery content. Quality and security in delivering medication must
be fully guaranteed. These systems require a medical order, and information regarding patient name, doctor, and
quantity of drug dispensed must be recorded.
In most Spanish hospitals, there is just one delivery a
day, in the afternoon, because in many hospitals doctors
see patients between 8 A M and 3 P M However, the
number of visiting hours is increasing and pharmacy
working procedures may have to adapt to the new situation. Parenteral admixtures and nutritional preparations. if chemically stable, are generally prepared for each
patient in a centralized unit (described later), labeled, and

then delivered with the rest of the medication. Cytotoxic

drugs require special control and handling and are not
normally sent with the rest of the medication. Sometimes,
in intensive care units and other acute care settings, drug
delivery is not based on a unit-dose system but on stocks
kept on the wards.
Some outpatient services are provided by the inpatient
pharmacy, but discharged patients in Spain cannot receive
drugs from the inpatient pharmacy. At discharge, patients
may receive drug information and a copy of their medication administration record for reference. Computer
software (InfoWinE) has been developed by a Spanish
group (with a Spanish drug database) for this purpose.
Drugs that require a special delivery procedure are:

1. Drugs for compassionate use. Hospital pharmacists have to control the ordering, dispensing, and
use of compassionate-use drugs. These are drugs
for nonauthorized indications andlor research
drugs not included in a clinical trial. In Spain,
activities in relation to these drugs are regulated.[.71 In order to use a drug for compassionate
care, the pharmacy service of the hospital applies
to the Direccih General de Farmacia y Productos
Sanitarios with the following documents: a clinical
report in which the doctor justifies the application
for the drug, a consent form signed by the patient,

Hospital Pharmacy Practice in Spain

and a form signed by the hospital medical director

who is responsible for drug use. It is common
practice for the pharmacy service to prepare a
technical report with relevant references to support
the application and to inform hospital directors of
the process.

2. Research drugs. Regarding drugs for clinical trials

conducted at the hospital, the pharmacy service is
responsible for their reception, storage, dispensing,
distribution, and return of unused drugs. Spanish
requirements are that clinical trials be regulated.[17' A copy of the clinical trials committee approval must be kept at the pharmacy service, and
dispensing is done only after a written and signed
prescription is received.

3. Foreign drugs. Drugs marketed in a foreign country but not available in Spain may, according to
Spanish law, be obtained but only for the specific indications for which the drug is approved in
that foreign country."] The hospital pharmacy service applies to the Direcci6n General de Farmacia
y Productos Sanitarios with the necessary documentation for use with an individual patient or
according to a protocol.

457

macy service. A sterile area is normally achieved with a

vertical or horizontal airflow hood.

Centralized units of intravenous therapy (or CIVAS, for

'*central intravenous additive service' ') were created in
Spanish hospital pharmacy services as both a consequence
of the growing importance in the hospital of intravenous
drugs, and parenteral nutrition and fluids and as a
consequence of the clinical and technical progress in this
area of the pharmacy. In recent years. Spanish hospital pharmacy services are almost obligated to have a
CIVAS,"91 and it is now considered, along with the unitdose distribution system, one of the main units in the
pharmacy service.[l'] The main objectives of the CIVAS
are preparation of products therapeutically and pharmaceutically appropriate for the patient (right dose, administration route, chemically compatible, stable); preparation of admixtures free of particles, microorganisms,
or toxins; preparation of admixtures with the correct
drug in the exact amount; labeling, identification, storage, and distribution of admixtures according to good
drug control principles; cost control of intravenous
fluids; monitoring and clinical follow-up of patients;
drug use evaluation studies; and participation in the

4. Stocks in wards. There are some drugs (e.g.,

urgent medications, PRN, drugs dispensed as
needed) and medical devices that have to be in
stock on the ward. These are normally sent to the
floor on a regular basis, according to a fixed
schedule. These stocks are periodically checked
by pharmacists (with regard to composition, expiry date, correct identification), and the results of
the control are filed. The nurse supervisor of each
ward is responsible for the safekeeping of the
stock; the pharmacist is responsible for control
and supervision.

Manufacture
Manufacture implies the manipulation of active substances and drugs in order to make them suitable for direct
administration to patients. Separate areas are needed for
the manufacture of intravenous admixtures and parenteral
nutrition, cytotoxic drugs. and sterile preparations. No
separate areas or biological security are needed for other,
nonsterile preparations or drug repackaging. Following
Spanish regulation,"*] written protocols and procedures
for manufacturing processes must exist in every phar-

Fig. 4 Nurse preparing an anticancer drug in a central unit in

a Spanish hospital pharmacy service.

458

intravenous therapy policy of the hospital (indications,

selection, preparation, administration, etc.).
Most hospitals have a computerized CIVAS that is
integrated into the unit-dose distribution system. Preparations handled in these units include cytotoxic drugs,
antibiotics. parenteral nutrition, other drugs, and therapy with fluids (Fig. 4). References to Spanish articles
dealing with recommendations for managing these units
can be found in the b i b l i ~ g r a p h y . ~Pr~otocols
~ ~ , ~ ~must
.~~~
include every procedure carried out in the unit, from
preparation to identification, hazard handling, waste treatment, and so on. In Spain, admixtures and nutritional
preparations are normally prepared by pharmacy nurses
supervised by pharmacists.
Centralized units have some advantages, such as less
investment in equipment, better use of multidose vials,
recycling of unused preparations, better working conditions, a good opportunity for clinical intervention by
pharmacists, and improvement in the quality of patient
care when the CIVAS is well coordinated with the unitdose system.

Hospital Pharmacy Practice in Spain

established in Spain, and today activities related to drug

information are part of every hospital pharmacy service.
Drug information is another area where clinical intervention by pharmacists could be increased.
Information provided by pharmacists can be classified
as passive or active. The former includes answering
questions and preparing the requests/controls for foreign,
compassionate-use, and research drugs. Active information includes providing support to the P&T committee
(drug formulary preparation, diffusion of main decisions),
establishment of protocols, writing of the drug information bulletin, sessions, adverse drug reactions programs,
advising in- and outpatients, health education activities,
information management, and so on. Some hospitals make
their drug formulary and other information available on
the Internet (e.g., www.hsanmillan.es/farma/index.htm)
and some participate in the dissemination of drug information, in the Spanish language, to patients.[321 Additional sources of information and recommendations for
the management of drug information centers that have
been proposed by the SEFH and others are given in the
bibliography. [7,8,11,21,221

Enteral and Parenteral

In Spain. preparation of enteral and parenteral nutrition is
carried out in the centralized units of the pharmacy services. Hardly any hospitals obtain their parenteral
nutrition preparations from an external company. In most
hospitals there are some standard nutritional preparations
as well as others designed for specific patients. Nutrition
design and patient follow-up is done by hospital pharmacists or by a team of various professionals (doctors,
dieticians, nutritionists, pharmacists), depending on the
hospital. Normally. laboratory data, clinical results, and
patient progression are observed by pharmacists and
nutrition support is changed accordingly, which gives
pharmacists another opportunity for clinical intervention.
References on how to manage such a service are given
in the bibliography.[73x3191
Computer software is used to
make this task easier, permitting data entry (general
patient data, lab results, prognosis, nutritional status, diet)
and preparation of working sheets, reports, and labels for
nutrition identification. Complications or incidents can
also be registered; some software programs include
Spanish products for nutrition support (e.g., NutriDataE,
Nutri2000E).

Drug information
Drug information is one of the main responsibilities of
pharmacists in hospitals and one of their most important
contributions to a rational use of drugs and better patient
care. In 1973, the first drug information center was

harmacok~~etic
and
Therapeutic Drug ~ ~ ~ i t o r ~ n g
Clinical pharmacokinetics is a multidisciplinary field that
has been growing in importance over the last 20 years. Its
main objective is therapy optimization by achieving drug
concentrations in the therapeutic range and thereby
obtaining maximum efficacy with minimum adverse effect. The concentration-effect relationship of many drugs
is better than the dose-effect relationship. This is due to
high interindividual variability. In these drugs, therapeutic
drug monitoring is justified.
To assure the best efficacy, the pharmacist designs a
pharmacotherapy that is specific to each individual patient. This is achieved by obtaining blood samples, gathering patient data (clinical situation. laboratory results,
physiopathology, progression, therapy), applying pharmacokinetic principles, and applying knowledge of drug behavior in the population in which the patient is included.
Even though drug concentration is an important piece of
information, it is not enough on its own and patient
follow-up is required. Times of sample collections must
be carefully established in order to obtain maximum information from the minimum number of samples.
The usefulness of therapeutic drug monitoring has
been demonstrated for some drugs (e.g., some antibiotics,
cardiovascular agents and antiepileptics, theophylline, inmunosupressants, litium, r n e t h o t r e ~ a t e ) , [ ~and
, ~ ~these
I
are
the drugs that are included in clinical pharmacokinetic
programs in Spanish hospital pharmacy units. The be-

Hospital Pharmacy Practice in Spain

nefits of therapeutic drug monitoring of other drugs, such

as some anticancer drugs, are now being studied in some
centers.[241
Sample analysis requires specific techniques, such as
fluorescence polarization immunoassay (FPIA) and highperformance liquid chromatography (HPLC). These techniques are not always available in the pharmacy and so
sample analysis is not always done in Spanish hospital
pharmacy services but in laboratories. However, it is a
pharmacist who interprets results, makes recommendations, and follows up on patients, all as part of clinical
activities to pursue better patient care. In all hospitals with
such a pharmaceutical service, doctors and other members
of the health team welcome the contribution of pharmacists, with their pharmacokinetic knowledge, to the
rational use of drugs.

Drug Surveillance
Drug surveillance includes drug follow-up with the purpose of observing, evaluating, and communicating any
adverse reactions that a drug can produce when used in
clinical practice. A drug surveillance program must be
established in every hospital in order to detect these
reactions, and the drug information center must support
this activity technically. Observed events are communicated to the regional center for drug surveillance, either
directly or through the SEFH. The Spanish Drug Agency[331facilitates drug surveillance activities and the diffusion of information among professionals. Spain has
an organized drug surveillance system-a national committee reporting to the Ministry of Health was constituted for this purpose in 1987. Spontaneous communication of adverse drug reactions is voluntary in Spain
and is conducted through an official form known as the
"yellow card.'"']

Radiopharmacy
In Spain, pharmacy practice is also applied to the study,
manufacture, control, and distribution of radiopharmaceuticals. Radiopharmaceuticals must be isolated from
other drugs and personnel, and devices must follow Spanish regulations.[251Radiopharmacy is part of the hospital pharmacy service; however, it is recommended that
the unit be located close to the nuclear medicine department and supervised by a pharmacist specialist in
radiopharmacyI'[.

459

Spain, pharmacoeoconomics is becoming more important

due to increased pressure to make the best use of limited
resources. Furthermore, advances in the methodology[261
have increased the scientific rigor of pharmacoeoconomics. Pharmacoeconomics is used by Spanish hospital
pharmacists as a tool for decision making regarding
drugs, medical devices, or related activities. Studies are
conducted and pharmacists adapt published studies to
each unique hospital setting.

Many Spanish hospital pharmacies participate in the

selection, ordering, storage, distribution, and provision of
information relating to medical devices. Such hospital
pharmacies are also involved in rational use programs. A
guide to medical devices used in Spanish hospitals has
been published, which gives a classification to each
device.[271

The number of activities conducted by hospital pharmacy

services is continually increasing as the needs of doctors,
personnel, and patients evolve. This gives the pharmacist
the opportunity to develop a range of activities (clinical
roles, management, administrative duties) that are of
interest to and positive for the hospital. Pharmacists must
continue to focus on the impact that technological and
professional changes may exert on the efficacy and safety
of medications as well as on patient care.
The role to be played by hospital pharmacists should
be determined by all health care professionals, not just by
pharmacists themselves. The 1999 meeting of the Spanish
Society of Hospital Pharmacists took this into account
and a roundtable was held incorporating representatives
of all health team members as well as a representative of
patient opinion based on a survey of patients. Better
information for patients, more integration of pharmacists
in the health team, and more direct contact with patients
seem to be the activities to be developed in the future.[2s1
Any activity that contributes to patient care must be
nurtured, no matter who suggests it. Pharmacists as well
as other professionals know that teamwork is the key to
improving results for the patient.

Pharmacoeconomics
Pharmacoeconomic evaluations consist of comparing
different alternatives in terms of costs and benefits. In

1. Ley 25/1990, de 20 de Diciembre, Boletin Oficial del

Estado (B.O.E.) del 21. del Medicamento. (Also at
www .msc.es/farmacia/legislacion/home.htm).

Hospital Pharmacy Practice in Spain

460

2.

Bonal, J . Management en Farmacia Hospitalaria. I n

I.'armnc,iu Hospitalaria, 2nd Ed.; Editorial MCdica Inter-

3.

4.

5.

6.

7.

8.

9.

10.
1I.

12.

13.

14.

15.

16.

national: Madrid, Spain, 1992; 30-55.

Suiik, J.M.; Rel. E. Coinpilucirjnde Legislario'n en I*hrmacin Ho,spilalaria, 2nd Ed.; Sociedad Espaliola de Farmacia Hospitalaria, Ed.; International Marketing and
Communications: Madrid, Spain, 1994; 1290.
Gitici de Formacidiz de l.q~c~ia1i.sta.s.
Famiacia Hospitalaria; Ministcrio de Sanidad y Consumo, Ministerio de
Educacihn, Cultura, Conscjo Nacional de Especialisaciones Farmac6uticas: Madrid, Spain, 1999; 3 1.
SuliC, J.M.; Bel, E. Legislacidn. In Fnrmariu Hospitdaria,
2nd Ed.; Editorial Mkdica Internacional: Madrid. Spain.
1992; 172-268.
Simh, R.M. Docencia. In Farmacia Hospi~ularia,2nd Ed.;
Editorial MCdica Intcrnacional: Madrid, Spain, 1992; 136157.
Guia de Gestio'n d r 10s Suvicios de F a m a t i n Hmpitalaria; Insituto Nacional de la Salud: Madrid, Spain, 1997,
(A1so at w w w .se f.es/guiafarmacia/home. h tm) .
Farinacia Hospitdaria, 2nd Ed.; J. Bonal, A. Dominguez(31. Dir.; Editorial MCdica Intcrnacional: Madrid, Spain,
1992, 1717 pp.
Guia para la Evaluucicin y Mejora de 10s Servicios de
Farmacia Hospitalaria; Insituto Nacional de la Salud:
Madrid, Spain. 1998, (Also at www.sef.es/guia/index.htm).
Situacihn de la Farinacia Hospitalaria. Encuesta- 1995.
SEFH Bol. Inf. 1996, XX (76), 100.
Curso de Adnziiiistrcicidn de Servicios I-lospitalarios de la
Clinicti Univei~itaria.El Sewicio de Farmacia: Universidad de Navarra: Pamplona, Spain. 1992; 509.
Ferrandir, J.K. Distribucihn unidosis dc Mcdicarncntos en
Hospitales. In X I X Asciniblpa National de Farmare'ulicos
de Ho.spita1e.s; Graficas Orihn: Madrid. Spain, 1975; 7 1 88.
Lcape, L.L.; Cullen, D.J.: Clapp, M.D.; Burdick, E.;
I>cmonaco, H.J.; Erickson, J.I.; Bates. D.W. Pharmacist
participation on physician rounds and adverse drug events
in the intensive care unit. JAMA, 1. Am. Med. Assoc.
1999. 282 (3). 267 270.
Scroccaro, G.; Alhs Almiiiana, M.: Floor-Schreudcring,
A,; Hekster, Y.A.; Huon, Y. The need for clinical
pharmacy. Pharm. World Sci. 2000, 22 ( l ) , 27 -29.
Atencihn FarmacCutica. In XIIV Congreso de la SEFH,
Pamplonci, Sept. 1999; Farm. Hosp.. 1999; Vol. 23, 3-6,
(Num. Especial).
Codina Jane, C. In Si.steiiza.s Expc,rto.r y Aplicacioiws 111XLTV Congreso Nacional de Farmacia Hospitalaria, Pamplona, Spain, Sept. 1999: Sociedad
Espafiola de Farmacia Hospitalaria: Madrid, Spain, 2000.

17. Real Decreto 561/1993, del 16 de ahril. Boletin Oficial del

Estado de 13 de Mayo. por el que sc estahlecen 10s
requisitos para la realiLacihn de cnsayos clinicos con
mcdicamentos.
18. Normas de correcta faabricacihn de fdrmulas magistrales y
preparados oficinales. SEFH Bol. Tnf. 1994, XVIII (69),
15 28.
19. JimCneL Torres, N.V. Mezclas, 1ntmveno.sa.s y Nutricicin
Artzfi'cial, 4th Ed.: C.E.E. Convaser: Godella, Valencia,
Spain, 1999; 722.
20. Manejo de Mrdicainentos Citostciticos, 2nd Ed.: Asociacidn Espaliola de Farmackuticos de Hospitales: Madrid,
Spain. 1987; 56.
21. Proyecto de recomendaciones de la SEFH: Informacidn de
medicarnentos. S E H Bol. Tnf. 1996, X X (77), 15 20.
22. Tordera, M.; Magraner, J.; FernBndez, M.I. Informacionde
medicarnentos e internet. Estrategias de btisqucda farrnacoterap6utica en la World Wide Web. Farm. Hosp. 1999,
23 (l), 1-13.
23. Applied Pharmacolzinetics. Principles of Therapeutic Drug
Monitoring, 3rd Ed.; Evans, W.E., Schentag, J.J., Jusko,
W.J.: Eds.; Applied Therapeutics, h e . : Vancouver, Washington, 1992.
24. AldaL, A. FarmacocinCtica de CitostBticos. Conceptos
Generales. In El Paciente Oncohematolrigico y su
Tratainirnto. Mddulos d~ Acrualizncicin Multidi.sciplinar;
SEFH, Editores Medicos, S.A.: Madrid, Spain, 1997; 3237.
25. Real Decreto 479/1903, de 2 de Abril, por el que se regulan 10s medicamentos RadiofBrmacos de uso hurnano
( I ) . Boletin Oficial del Estado nuin 109 de 7 de Mayo
de 1993.
26. Drummond, M.I:.; O'Brien, B.; Stoddart. G.L.; Torrance,
G.W. Methods ,for IZconomic Evaluation of Health Care
Pi-ogmmmes, 2nd Ed.; Oxford University Press, Tnc.: New
York, 1997; 305.
27. Giraldez, J.; Idoate, A,; Romero, R.; Urstia, C.; Errea,
M.T.; Lacasa, C.; AldaL. A. Guiu de P m d u c t o . ~Sanitarios,
2nd Ed.: ELNSA: Raraliain, Navarra, Spain, 1998; 508.
28. In El Medictrmenro en e l Prnceso de Atencio'n a1 Pacieizte.
Anu1i.si.s MLilridisci(r1inar. Poncncias XLIV Congrcso
Nacional dc Farmacia Hospitalaria. Pamplona: Spain,
Sept. 1999; Sociedad Espafiola de Farmacia Hospitalaria:
Madrid, Spain, 2000; 9-64.
29. Text available at www.msc.es/farmacia/legislacion/
home.htm
30. www.msc.es/centros/catalogo/home.htm.
31. See www.scih.es.
32. See www.viatusalud.coin.
33. See www.msc.es/agemed/.

PROFESSIONAL DEVELOPMENT

Oregon Health Sciences University, Portland, Oregon, U.S.A

INTW
Hyperlipidemia is a disorder that is widely prevalent in
the U.S. population. Elevations of total and low-density
lipoprotein (LDL) cholesterol have been documented to
increase the risk of coronary heart disease (CHD). The
Third National Health and Nutrition Evaluation Survey
(NHANES 111) estimated that 52 million Americans have
cholesterol elevations that require intervention, of which
12.7 million may require drug therapy."] A number of
studies have shown a reduction in cardiovascular mortality or morbidity with lipid-lowering therapy in
subjects with CHD (secondary p r e v e n t i ~ n ) [ ~ -and
~ I in
some patients without known CHD (primary prevent i ~ n ) . ' ~Despite
'~]
this, the use of lipid-lowering agents in
patients who have had a prior coronary event is disturbingly low.[81When drug therapy is initiated, compliance may be poor and adherence to therapy may be as
low as 35% in some s e r i e ~ . ~ ~Other
" ~ ' data indicate that
even where cholesterol-lowering drugs are prescribed,
many patients do not reach the goals of therapy recommended by the National Cholesterol Education
Program (NCEP).'"'
Hyperlipidemia is a disease particularly suitable for
pharmacist management for a number of reasons. It is a
disorder that can be diagnosed and monitored primarily
by laboratory testing. There are accepted guidelines for
LDL goals. The drugs that are used vary in their effectiveness for altering the different lipoproteins and
require someone skilled in this knowledge to select them
for use. The rate of adherence to drug therapy is low,
possibly in part because patients do not feel elevated
cholesterol and therefore do not understand the need to
take medication. These drugs are in some cases unpalatable or difficult to tolerate and require much patient
education to initiate therapy and maintain compliance.
Drug interactions with cholesterol-lowering agents can be
clinically significant. These include inhibition of absorption of drugs such as levothyroxin or warfarin given concurrently with bile acid binding resins, or inhibition of
the metabolism of statin drugs resulting in myopathy or
even rhabdomyolysis.
Eneyelopedin of Clinical Pharmacy
DOI: 10.1081/E-ECP 120006308
Copyright 0 2003 by Marcel Dekker, Inc. All rights reserved.

Pharmacist intervention was effective in maintaining

compliance and achieving LDL goals in patients treated
with colestipol."*] In a small study at a Veterans Administration (VA) Medical Center, patients received 1 hr of
education and assessment by pharmacists before initiating
colestipol therapy. They also were telephoned at 2-week
inervals until an 8-week follow-up appointment. They
were contacted by telephone again at 26 and 52 weeks.
When compared at 52 weeks with patients receiving usual
care, the pharmaceutical care group had greater persistence with colestipol therapy, were taking higher doses,
had lower mean LDLs, and had a higher rate of reaching goal.
The effect of weekly contacts with patients initiated on
combination lipid-lowering therapy of lovastatin and colestipol was inve~tigated."~]
Patients from a universityaffiliated tertiary care center were enrolled if they had
undergone coronary artery bypass graft surgery or percutaneous transluminal coronary angioplasty (PTCA). In
addition to instructions on appropriate drug use prior to
hospital discharge, patients were telephoned at home
weekly for 12 weeks at which time "emphasis was placed
on the importance of therapy in reducing the risk of
cardiac events." Interestingly, when these patients were
compared with a control group at the end of the 12 weeks
compliance with therapy was high in both groups and not
significantly different. However, when refill history was
obtained from the patients' pharmacies at 1- and 2-year
intervals, the patients in the intervention group had significantly higher rates of compliance.
Provision of patient education in combination with bimonthly cholesterol testing in a community pharmacy resulted in a significant reduction in cholesterol values over
a 6-mo study."41 Changes in patient-reported behaviors
such as dietary habits and exercise were also noted. Although the lack of control group made this study less than
definitive, it indicated that a combination of cholesterol
monitoring and education could result in lower cholesterol
concentrations. A second study demonstrated that screen461

Nyperlipidemia Pharmacy Practice

462

ing in combination with education and referral to a primary care physician when appropriate resulted in a significant
number of patients receiving follow-up for cholesterol
concentrations that were higher than the NCEP goal^."^'

Hyperlipidemia management can exist wherever pharmacists practice, including community pharmacies, institution-based or free-standing ambulatory clinics, or
inpatient services. Despite these different settings, some
universal requirements need to be addressed.
The nature of the practice may be influenced by the
availability of space in which to provide patient care. For
example, the lack of facilities in which to meet privately
with the patient may result in a telephone-based practice.
Offering lipid management in the community pharmacy
may require an investment in infrastructure. Some remodeling of the pharmacy may be needed to provide an
area where confidential communications can occur. A
lipid analyzer, as well as a dedicated clean area, must be
supplied if blood lipid monitoring is to be offered.
Staffing must be adequate. A redistribution of duties
among pharmacists and technicians, possibly in addition
to hiring additional pharmacists, may be necessary to
allow pharmacists time to provide the service."61
Most pharmacists will need to justify their provision of
this service, whether it be in the form of a business plan
for an independent pharmacist or a proposal demonstrating benefit to an institutional employer. If the pharmacist
will be relying on referrals to the service or will be
collaborating with physicians to implement therapy, the
pharmacist must first determine whether physicians will
use the service and be accepting of input. An evaluation
of a cholesterol screening program found that a significant
number of physicians in the geographic area were resistant to their patients directly receiving the results of
their cholesterol tests from the pharmacy. These physicians were less likely to contact patients with the results
of elevated cholesterol values obtained at the screening."71 Patients may also be surveyed as to acceptance of
pharmacist management, particularly if they are going to
be expected to pay part or all the costs of the service.
In all models, a scope of practice agreement or protocol is recommended, if not required. This should outline
the following:

1. The hours of operation.

2. The pharmacists who are responsible for providing
the service.

The supervising physician, if applicable. This may

be especially needed if the pharmacist has prescriptive authority.
The population to be managed. For example, in the
case of limited resources, the service may be restricted to secondary prevention patients, patients
requiring combinations of drugs, or those with
mixed lipid disorders versus those with only elevated LDL, or other parameters as determined by
the needs of the facility.
The means of identification of patients. This could
vary from seeing potentially low-risk patients,
such as any patient followed in a general medicine
clinic or referred by a primary care provider, to
identifying high-risk patients, such as anyone discharged from the hospital with a diagnosis of
myocardial infarction or after a revascularization
procedure or with other evidence of CHD risk.
The goals of the clinic and methods for achieving
them. Explain how patients will be evaluated and
how the need and type of therapy will be determined. Describe any protocols for deciding on
drug therapy or the rationale for allowing clinical
decision making instead of following an algorithm.
Will patients be seen once for evaluation and recommendations, as often as necessary to achieve
control, or indefinitely? How frequently will they
be seen? Will all contacts be by visit, or will telephone calls be routinely used?

The functions of a pharmacist in lipid management in a

community setting may include screening for elevated
cholesterol and/or low HDL cholesterol, providing patient
education and counseling to enhance adherence with drug
and nondmg therapy, monitoring of lipid profiles for assessment of efficacy, and making recommendations to
providers for drug therapy management.

Screening programs
The accessibility of community pharmacists to both patients and physicians makes them an ideal resource for
identifying the presence of lipid abnormalities. Screening
may consist of offering to measure cholesterol levels to
the general population, or may involve targeted screening
of patients at high-risk for CHD, also called case finding.
In either case, screening should involve more than pro-

Hyperlipidemia Pharmacy Practice

vision of a laboratory value. The total and HDL cholesterol values should be evaluated and interpreted in the
light of the patient's risk factors for CHD. Education
about cholesterol and cholesterol-lowering strategies
should be provided, and the pharmacist should be prepared to refer the patient to their primary care provider if
warranted. Failure to interpret these values may result in
unnecessary concern on the part of the patient or, potentially more damaging, result in a patient not seeking
care when needed.
Gardner and colleagues['s1 demonstrated that a community pharmacy prescription database can be used to
identify patients at risk for CHD. This is important
because it targets those individuals most likely to benefit
from lipid-lowering interventions. They identified four
clinical indicators that were believed to be likely to
identify patients at risk for CHD: prescription for sublingual nitroglycerin, prescription for beta-adrenergic
blocking agents or thiazide diuretics, males with a prescription for nicotine gum or patch, or those receiving oral
hypoglycemic agents or insulin therapy and who were
greater than 50 yr of age. A search of the pharmacy
database was performed to identify individuals prescribed
at least one of these agents, and the pharmacy profiles
were screened to ensure the age and sex met the criteria.
These subjects, who were invited to a free cholesterol
screening, were compared with an unselected population
who self-referred to the screening. Twenty-one percent of
those identified as high risk responded to the invitation. A
significantly greater percentage of the screened patients
had cholesterol values that were higher than desired. In
addition, two-thirds to three-fourths of the patients with a
clinical indicator had cholesterol values over 200 mg/dl,
indicating that these indicators may be predictive of the
need for cholesterol-lowering intervention.
Einarson et a ~ [ 'reported
~]
the financial feasibility of a
pharmacy-based cholesterol screening program. Subjects
were asked how much they would be willing to pay for a
cholesterol measuring service in a pharmacy. Patients
who completed a pharmacy service questionnaire indicated they would be willing to pay a mean of S11.54.
Patients who received the service were surveyed afterward, and indicated a willingness to pay $14.47 (1987
dollars). Of note, it does not appear that these patients
received pharmacist education as part of their testing but
were reacting to the value of obtaining cholesterol results
at a pharmacy.

Lipid management practices

Shibley and Pughi201 described the provision of pharmaceutical care in independent community pharmacies.

463

Patients were recruited by the investigator and included in

the study if their primary physicians agreed to allow them
to do so. The physicians were recruited by letter and by
meetings with the pharmacists. Pharmacists provided
basic education about lipid disorders, the relationship to
coronary artery disease, and diet and exercise. Lipoproteins were measured at the pharmacy using the CholestechE analyzer. If warranted, drug therapy recommendations were provided to the physician via telephone or
letter; if accepted, the patient was seen at 2 months to
assess efficacy and adverse effects. All patients were also
seen by a certified dietician. Significant reductions in
LDL cholesterol were observed, although it is not clear
how many patients reached their therapeutic goal. Given
choices ranging from $15 to $55, patients indicated they
would be willing to pay $23.75 &$11.42 for each encounter with the pharmacist.
Project ImPACT: Hyperlipidemia was a multicenter
community pharmacy-based demonstration project that
aimed to demonstrate the benefits of a pharmacist on
patient adherence and compliance with lipid-lowering
therapy.[16] The pharmacists used cholesterol analyzers at
their sites to enhance their interactions with patients and
their physicians. Emphasis was placed on patient education and communication with the physicians to bring
patients to their NCEP cholesterol goals. Of interest,
62.5% of the patients, who were predominantly primary
prevention, did reach and maintain their goals by the end
of the study. Persistence with therapy was excellent, with
93.6% remaining on the prescribed cholesterol-lowering
agent throughout the study. Compliance with therapy,
defined as fewer than five missed doses or refills obtained
within 5 days of when due, was 90.1%. Physician acceptance of pharmacist interventions was high, with 76.65%
of recommendations resulting in a change. These interventions involved coordination of care, adverse drug reactions, drug interactions. drug dosing, drug selection, and
side effects.
The participating pharmacies were primarily independents, with some chains, clinic pharmacies, health maintenance organizations, and home health/home infusion
pharmacies. All pharmacies scheduled patients for appointments with the pharmacist. Most used time before
the regular pharmacy hours or on weekends, as well as
during usual business hours. Seventy-two percent of sites
changed the pharmacist's duties to accommodate this new
role, and 59% changed technician duties. Increasing pharmacist overlap was also a commonly used strategy. Fewer
than one-third added pharmacist staff to implement the
program. The average amount of time spent on patient
encounters was about 45 min for a new patient and 22 min
for a follow-up appointment.

464

Development of lipid management practices in the institutional or free-standing clinic settings may take many
forms. The types of practice can range from provision of
consultative services by pharmacists in conjunction with
patients appointments with their primary care provider,
to free-standing pharmacist-managed clinics in which the
pharmacist has prescriptive authority to initiate, discontinue. and change drug therapy.
Pharmacists in a consultative role improved management of lipid disorders in an ambulatory internal medicine
In this study, the pharmacist met with patients
prior to their physician appointment. Medication histories were taken. compliance encouraged, drug costs were
tracked, and the least costly recommendation made to the
physician. The pharmacist reviewed laboratory data and
recommendations with the physician and attached a copy
of these to the front of the chart. Decisions to accept or
decline the recommendations were made by the physician.
The majority of recommendations were accepted. When
compared with usual care where pharmacists were not
involved, significantly more patients reached LDL goals.
Furmaga[**] described the structure of a pharmacistmanaged lipid clinic at a VA Medical Center outpatient
clinic. Initially patients were identified using the hospital
computer database to identify those with a total cholesterol of greater than 260 mg/dl. These patients were
invited to a general educational seminar and subsequently
scheduled into the lipid clinic, if needed. As this resulted
in more patients identified than could be reasonably
accepted into the clinic, the system was changed so that
patients were referred from outpatient clinics. Patients
were scheduled for 30-min appointments. The activities of
the pharmacist included patient education, identification
of secondary causes of hyperlipidemia with subsequent
referral to other clinics as indicated, compliance assessment, and intervention and recommendation of addition of
drug therapy to diet therapy. Clinical judgment was used
in lieu of a protocol for drug selection. The pharmacist did
not have prescriptive authority but was responsible for
monitoring of drug therapy for efficacy and adverse
events, and determining when changes were needed. Activities were documented in the medical record.
Shectman and colleagues[231demonstrated that use of
physician extenders resulted in improved LDL cholesterol
concentrations when compared with usual care. In this
model, also at a VA hospital clinic, the pharmacist or
nurse used an algorithmic stepwise approach to assist in
drug selection and optimization in reaching NCEP LDL
goals. More patients reached their LDL goals in the
physician extender group. The total costs of the physician

Hyperlipidemia Pharmacy Practice

extender care was higher. primarily due to higher drug

costs. The cost per unit of LDL lowering, however, was
significantly less.

Inpatient pharmacists can also provide care by helping to

initiate lipid-lowering therapy. In addition to the data that
support treatment to lower cholesterol in patients who
have had a coronary event, the National Committee for
Quality Assurance is instituting a new Health Plan Employer Data and Information Set (HEDIS) indicator for
cholesterol management in patients who have experienced
an acute cardiovascular event. This will provide a challenge to identify and treat patients with coronary artery
disease. A program by which pharmacists identified patients through acute myocardial infarction/percutaneous
transluminal coronary angioplasty orders has been detailed.[241Pharmacists placed a standardized note on the
outside of the patient chart that included the goals of
therapy and recommended that a lipid panel be obtained.
The proportion of patients receiving lipid-lowering therapy at discharge was significantly increased after initiation of the program.

harmacist Education and Trainin

Regardless of the practice setting, a pharmacist needs
certain tools to provide lipid management services. The
first tool is an in-depth understanding about the disease
and antihyperlipidemic drugs. Understanding of the disease includes knowledge about lipid metabolism, the influence of lipids on atherogenesis and vascular function,
the risk of dyslipidemia and CHD mortality and morbidity, and the benefits of lipid-lowering as demonstrated in
clinical outcome trials. Knowledge of the drugs includes
pharmacology, pharmacokinetics (especially as pertains
to the potential for drug interactions), adverse effects that
are most often experienced or most severe, and how to
manage these effects. The influence of each drug on the
various lipoproteins, the effects of dose on lipoprotein
lowering, the risks and benefits of combination therapy,
and the goals to be targeted should be known. This type of
education can be obtained through self study or by attending certificate programs, conferences, or other training programs.
The American Pharmaceutical Associations Pharmaceutical Care for Patients with Dyslipidemias is a

465

Hyperlipidemia Pharmacy Practice

2-day training session that includes material on evidence

of cholesterol-lowering and use of antihyperlipidemic
agents, training on the CholestechE analyzer, discussions
on preparing the pharmacy practice site to provide the
service, marketing to patients and physicians, communication with physicians, and reimbursement and billing.
The National Pharmacy Cardiovascular Council offers a
comprehensive three-tiered educational program. The Lipid Managers Training Program begins with the basics
of lipid disorders and progresses to on-site training in a
lipid clinic.[321Many state organizations offer certificate
programs in lipid management.
The NCEP was initiated by The National Heart, Lung,
and Blood Institute (NHLBI) of the National Institutes of
Health (NIH) in 1985. The goal of this program is to
promote cholesterol awareness in the U.S. population as a
risk factor for CHD and provide guidelines for cholesterol-lowering to physicians, patients, and the community, thus reducing CHD mortality and morbidity. The
program consisted of five panels that are responsible for
evaluation of the evidence and establishing guidelines in
PATIENT NAME
REFERRING CLINIC/ PROVIDER

ID#

their specific areas: the Expert Panel on Detection,

Evaluation, and Treatment of High Blood Cholesterol in
Adults (Adult Treatment Panel or ATP) develops guidelines for the detection, evaluation, and treatment of high
blood cholesterol in adults; and the Expert Panel on
Blood Cholesterol Levels in Children and Adolescents
developed recommendations for healthy diets for children
and adolescents, and for detection and treatment of high
blood cholesterol in children and adolescents from highrisk families.
The guidelines for treatment recommended by the
ATP are considered the standard for dietary and drug
therapy in adults. The most recent guidelines were released in May 2001;r251the panel is currently revising
these and updated guidelines are anticipated after Spring
2001. The pediatric guidelines were released in 1992.r261
The American Diabetes Association clinical practice
guidelines make recommendations for managing hyperlipidemia in persons with diabetes that are more aggressive than the current NCEP guidelines, as well as more
specific to this population.[271
DOB
HT:
PRIOR DIETARY CONSULT / INTERVENTION?

DX:
SMOKER?
RISK FACTORS:
MALE > 45 YR
DIABETES
HTN

ETOH? (QUANTITY):

FEMALE > 55 YR
SMOKING
CVD

LDL GOAL

TG GOAL

CHD
FAMILY HX
PVD

Fig. 1 Sample lipid monitoring form.

HDL > 60?

Hyperlipidemia Pharmacy Practice

466

atie

ucation

not be product specific but will contain a company logo

and product brand names.

The second set of tools involves imparting some of this

information to the patient. This can be done verbally,
with written educational materials, with videotapes, or a
combination thereof. The level of the material should be
adjusted for the educational level of the patient population. The information should include definitions of
cholesterol, triglycerides, and lipoproteins; factors that
increase or decrease these values; and the goals for the
patient. A risk calculator that can be used to illustrate to
patients how their individual factors increase or decrease
their risk of a coronary event should also be included.[2s1
In patients without physical limitations, handouts and
counseling about beginning an exercise program may be
provided, although patients with known vascular disease
should be referred to their primary care provider for
guidance on appropriate activity. Providing a diary in
which patients can document their activity, heart rate,
notes on dietary changes, and weights can be helpful,
especially in the initial stages of making lifestyle
changes. Information sheets about the individual drugs
should also be distributed. The American Heart Association (AHA) web site provides a variety of tools for the
health care provider to order for a fee or to download at
no charge.[291
Pharmacists who practice lipid management should be
familiar with dietary factors that influence lipids. If
referrals to a dietician are allowed by law, the pharmacist
should have a referral base from which to guide the patient. Handouts that describe the goals of fat content,
specific foods to choose and avoid, and how to read and
interpret food labels should be available for distribution.
These are available from a variety of sources. Patients
may be referred to the AHA web site, which offers information about recommended diets as well as recipes. Drug
companies that market cholesterol-lowering medications
often provide free patient information materials that may

The third set of tools involves the pharmacists documentation of interventions and results. If lipids are to be
measured and followed, the use of a monitoring flow
sheet is extremely useful (Fig. 1). Flow sheets may be on
paper files, created on computer spreadsheets, or use special software programs.
Initial demographic data including height should be
collected. The information obtained at each visit should
include weight, exercise, lipid values, drug therapy (if
any), and compliance. If available. other pertinent labs
such as glucose or hemoglobin AlC, liver transaminases,
or measures of renal function should be noted. A comments section is useful to document items such as adverse
drug effects, noncompliance, o r other issues that can affect lipid control.

Communication
The fourth set of tools regards communication with physicians or other primary care providers. Interventions made
by the pharmacist or recommendations to the physician
may be made by telephone, letter, fax, or personal contact,
depending on the practice setting. These communications
are important in both obtaining and maintaining provider
buy-in as well as demonstrating the active role the pharmacist is playing in the care of the patient. In addition,
there is less likelihood for misunderstanding than if all
information is provided by the patient.

Lipid Measurement Devices

Lipid analyzers are not necessarily a needed tool for
providing lipid management services but can be very

Table 1 Cholesterol monitoring tests granted CLIA waived status

System

Manufacturer

Advanced Care
Cholestech LDX

Johnson & Johnson

Cholestech

Accu-Chek InstantPlus
ENA.C.T Total Cholesterol Test
Lifestream Technologies Cholesterol Monitor
Polymer Technology Systems (PTS) MTM
Bioscanner 1000 (for OTC use)

Boehringer Mannheim
ActiMed Laboratories
Lifestream Technologies
Polymer Technology Systems, Inc.

(Adapted from Ref. [31].)

Lipoprotein measured
Cholesterol
Total cholesterol, HDL,
triglycerides, glucose
Cholesterol
Cholesterol
Cholesterol
Cholesterol, HDL

Hyperlipidemia Pharmacy Practice

helpful. They allow the pharmacist to provide information and make recommendations for dietary and drug
therapy at the time of the interaction, instead of having
to schedule another time or attempt to reach patients by
phone. It allows reenforcement of the information
provided at the last visit as the patient can see the results of the intervention, and the implications of adherence or nonadherence to therapy can be demonstrated and discussed, and strategies for improvement can
be presented.
Measuring cholesterol in the practice setting requires
both the equipment and the legal authority to perform
testing. The 1988 Clinical Laboratory Improvement
Amendments (CLIA) established quality standards for accuracy, reliability, and timeliness in all laboratory testing.
Certain devices are considered to be of low complexity
and are therefore regarded as CLIA waived, which means
that the site where they are used must be enrolled in the
CLIA program but that routine on-site visits and monitoring are not required.
The cholesterol measuring devices that are in the CLIA
waived category are listed in Table 1. At this time, the
only waived analyzer that measures total and HDL cholesterol and triglycerides is the Cholestech LDXE. State
law will also need to be followed because some states, for
example, do not permit pharmacists to act as laboratory
directors or to obtain blood via finger stick. Information
about obtaining CLIA certification, a list of waived devices, and contact information for state survey agencies may
be found on the CLIA web site.'301

Although obtaining reimbursement is beyond the scope of

this chapter, a number of studies have tried to assess what
patients will pay or perceive to be the value of provision
of cholesterol monitoring and lipid management. The data
range from assessing the value of a cholesterol level
without attendant counseling to how much patients believe insurance companies should pay for each visit to the
pharmacist where education and medication review and
management are provided.
Project ImPACT is one of few studies that reports
actual billing and reimbursement results. Both patients
and insurers were billed for services. On average, pharmacists billed $28 for counseling services and $27 for
lipid profiles. Seventy-five percent of patients billed paid
an average of $35 per visit, and 53% of third-party payers
paid an average of $30. Reimbursement by third-party
payers was more frequent, however, for lipid profiles than
for counseling.

467

Pharmacist practices in hyperlipidemia management have

been shown to be effective in improving compliance,
adherence to therapy, and LDL lowering. Studies that
establish cost effectiveness are limited and are needed to
support efforts to expand pharmacist involvement and
justify reimbursement.

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Cardiol. 1999, 34, I348 1359.
w w w . a rn c ri c a n h e a rt . o rg / C A P/ p ro / p ro ~ -~ c t ( ~ o l s . h t m l
(accessed October 2000).
www.hcfa.gov/medicaid/clia/clialiome.htm (accessed
October 2000).
www.hcfa.gov/medicaid/clia/waivctbl.htm (accessed
November 2000).
www.npccnet.org/ (accessed November 2000).

PROFESSIONAL DEVELOPMENT

Steven C. Ebert
Meriter Hospital, Inc., Madison, Wisconsin, U.S.A

INTR

Since the 1980s, the specialty area of infectious diseases

within pharmacy practice has evolved into a distinct
discipline that is directed at providing optimum antimicrobial therapy to patients. The pharmacist is uniquely
qualified to apply therapeutic, pharmacokinetic, and
pharmacodynamic principles to antimicrobial therapy.
These skills serve to complement rather than compete
with the roles of infectious diseases physicians. Infectious
diseases pharmacists are employed in private and teaching
hospitals, clinics, academia, and industry. Literature that
document the positive impact of the infectious diseases
pharmacist on patient outcomes is now being published.

Education and Postgraduate Training

Infectious diseases pharmacists have typically been
awarded either a postbaccalaureate or entry-level Doctor
of Pharmacy degree. In addition, most have completed 2
to 3 years of postdoctoral training that consists of a 1-year
residency in pharmacy practice, followed by either 1 year
in an infectious diseases specialty residency or a 2-year
infectious diseases fellowship. It should be noted, however, that a select number of motivated practitioners have
not completed these postgraduate training programs, but
instead have become proficient in infectious diseases
through on-the-job training.

Pharmacists who have been practicing for more than 3

years and/or have completed postgraduate training may
become certified in pharmacotherapy (BCPS) through the
Board of Pharmaceutical Specialties (BPS). This certification is achieved via examination. In addition, as of the year
2000, BCPS awardees could be granted Added Qualifica-

Encyclopedia of Clinical Pharnzacy

DOI: 10.1081iE-ECP 120006229
Copyright D 2003 by Marcel Dekker, Inc. All rights reserved.

tions in Infectious Diseases Pharmacotherapy by submitting an application to BPS. The application consists of a
portfolio that describes the applicants practice in infectious diseases pharmacotherapy. The portfolio includes[]

1. A letter from applicant requesting review of

portfolio for purpose of granting Added Qualifications in Infectious Diseases Pharmacotherapy.
2. Current curriculum vitae (CV).
3. A detailed summary of each of the following
elements (if not included in CV):
a. Any special training or professional development programs in the area of infectious
diseases pharmacotherapy.
b. Work experience in the area of infectious
diseases pharmacotherapy.
c. Specific professional responsibilities for care
of patients with infectious diseases in outpatient and inpatient settings.
d. Any professional awards, honors, or special
achievements relative to infectious diseases
pharmacotherapy .
e. Bibliography of applicants relevant professional publications.
f. List of applicants past and present research
or other scholarly activities in the area of
infectious diseases pharmacotherapy.
g. Summary of past and current educationalhnservice activities for health care professionals
in infectious diseases pharmacotherapy.
h. List of memberships in professional organizations relative to infectious diseases, with
specific notation of any service or leadership
activities to the organization.
At this time, Board Certification in Pharmacotherapy
with Added Qualifications in Infectious Diseases is a
means for recognizing outstanding practitioners. It is not a
means of licensure or a prerequisite for practicing in the
area of infectious diseases pharmacotherapy.

469

Infectious Diseases Specialty Pharmacy Practice

470

Hsspit

ice

Pharmaceutical care of the hospitalized patient with infection is the most traditional role for infectious diseases
pharmacists. Numerous opportunities for proactive interventions in antimicrobial selection, dosing, route of administration. and monitoring of patients with changing
clinical status make this a popular practice setting for
many individuals.

macists trained in infectious diseases may practice in a

clinical setting that requires not only expertise in antimicrobial therapy, but also other therapeutic areas. For
example, an infectious diseases pharmacist may practice
as a clinical coordinator who is charged with developing
practice areas such as cardiology, nutrition support, etc.,
in addition to antimicrobial management programs. Other
practice sites that require a working knowledge of infectious diseases include clinical pharmacokineticists, critical care pharmacists, and transplant pharmacists. These
practice positions are typically funded 100% by the hospital in which they are located.

Practice solely in infectious diseases

Infectious diseases pharmacists typically practice in a
hospital setting that allows them to devote all their time
to managing antimicrobial therapy. All aspects of infectious diseases pharmacotherapy, including interventions on antimicrobial selection, antimicrobial dosing,
and intravenous-to-oral conversion are the responsibility
of the infectious diseases pharmacist. In addition, the
pharmacist is usually responsible for analyzing new
antimicrobials for formulary inclusion, medication use
evaluations. and antimicrobial restriction or therapeutic
interchange policies.
Some infectious diseases pharmacists may collaborate with infection control practitioners to reduce nosocomial infections and control antimicrobial resistance.
Others may work closely with clinical microbiologists
to design institution-specific susceptibility testing and reporting methods, and to generate periodic antibiotic susceptibility reports.
In hospitals with a significant pharmacy influence on
antimicrobial therapy, it may be impossible for the infectious diseases pharmacist to perform all the functions
described here. Instead, the pharmacist may need to
delegate the responsibility for conducting standardized
antimicrobial protocols (therapeutic interchange. intravenous to oral, aminoglycoside pharmacokinetics) to
other pharmacists, while maintaining accountability for
the quality of these programs.
Although the salary for many hospital pharmacists who
practice exclusively in the area of infectious diseases
comes from the hospital in which they practice, a substantial number are cofunded by hospitals and schools of
pharmacy or medicine.

Combined with other responsibilities

In hospital pharmacy departments with limited resources
or incomplete antimicrobial management programs, phar-

An increasing number of infectious diseases pharmacists

practice in outpatient settings. These individuals usually
practice in one of two areas. One area is in outpatient
clinics, where they are directly involved in patient care.
This is particularly true for pharmacists who specialize in
treatment of patients infected with human immunodeficiency virus (HIV) or other chronic infectious diseases
(e.g., leprosy). Pharmacists take medication histories,
counsel patients about their medications, assess response
to antimicrobial therapy, and make adjustments in therapy, as necessary.
Infectious diseases pharmacists also make valuable
contributions to patient care in the managed care setting. By evaluating antimicrobial prescribing patterns,
creating drug treatment protocols, directing formulary
decisions. and counterdetailing prescribers, infectious
diseases pharmacists help to curtail inappropriate antibiotic prescribing that may lead to increased antibiotic resistance.

a c e u ~ i c Industry
~l
An increasing number of infectious diseases pharmacists
have found a career in the pharmaceutical industry. Some
initially take positions in pharmaceutical sales. Others
may be hired as research associates, where they assist in
the collection and analysis of data for clinical studies.
More often, they are hired as medical science liaisons.
These individuals interact with physician and pharmacist
practitioners, where they provide drug information, grant
support for research and educational efforts, assist in
medication use evaluations, and give in-services to medical and pharmacy staff.
Promotions within industry have lead many of these
pharmacists into advanced positions such as Director of
Medical Affairs. Associate Director for Research, or Associate Director for Education.

Infectious Diseases Specialty Pharmacy Practice

esearch ~rganization
Some infectious diseases pharmacists join contract research organizations. These organizations work primarily
with pharmaceutical companies to test the in vitro activity
of new antimicrobials, assess their efficacy in intro and
animal infection models, and conduct clinical trials. Pharmacists may be hired into positions ranging from researcher to director.

Government
Some infectious diseases pharmacists have been hired into government positions. These individuals direct government-initiated studies, care for patients in clinics, and
formulate policies regarding medication use. Infectious
diseases pharmacists currently hold positions in the Food
and Drug Administration, National Institutes of Health,
and World Health Organization.

Independent Consultant
Many infectious diseases pharmacists devote some time
to work as consultants. In most cases, they serve as ad
hoc consultants for pharmaceutical companies, where
they assess the likely impact of a newer antimicrobial
andlor providing advice on direction of future studies.
They may also educate pharmaceutical sales staff or write
review articles.
Other infectious diseases pharmacists work full time
as consultants. Usually, they are employees of larger
consulting firms that are hired by hospitals or other health
care institutions to detect inefficiencies in process and to
improve financial success.

ICAL PRACTICE SETTl

Hospital Setting

Rounding with an infectious diseases

consult service
Most infectious diseases pharmacists who practice in a
hospital setting round with an infectious diseases consult
service. This service usually consists of an infectious
diseases physician, an infectious diseases medical fellow,
medical students, an infectious diseases pharmacist, and
(possibly) pharmacy students, residents, or fellows. Patients are usually identified through infectious diseases
consults. The pharmacist usually acts to optimize
the antimicrobial regimen by adjusting antibiotic doses

471

and apprising the service members of any imminent drug

interactions or adverse effects. The pharmacist also
monitors patients followed by the service, to assess
therapeutic response and/or adverse events. Finally, the
pharmacist serves as a resource for drug information for
service members.
The advantages of rounding with an infectious diseases
consult service include a sense of teamwork and
camaraderie; the backing of an infectious diseases physician, which means that most recommendations will be
followed; direct interaction with only a limited number of
(infectious diseases) physicians, which will quickly
establish mutual trust and respect; and the potential for
collaboration in research. Disadvantages include limited
patient exposure (usually only patients involved in consults are followed) and, potentially, limited usefulness if
the infectious diseases attending physician is knowledgeable in antimicrobial pharmacology.

Pharmacist-infectious diseases
physician collaboration
Another common practice model for hospital-based
pharmacists is a one-on-one collaboration between an
infectious diseases pharmacist and an infectious diseases
physician. Under this model, the infectious diseases
physician is generally responsible for standard infectious
diseases consults. The pharmacist acts as an extension
of the infectious diseases physicians clinical practice
clinical practice, rather than competition or duplication.
The pharmacist identifies patients in whom antimicrobial
therapy is suboptimal (i.e., wrong drug, wrong dose,
questionable indication, potential for IV-to-oral conversion). After conferral with the infectious diseases physician, an intervention is recommended or implemented.
These interventions usually follow predefined criteria established by the Pharmacy and Therapeutics Committee.
Some advantages of this model are the establishment
of a close relationship between infectious diseases
physicians and pharmacists, the backing of the infectious
diseases service and the Pharmacy and Therapeutics
Committee on interventions, and the potential for
pharmacists to bill for clinical pharmacy services through
a physician provider. Potential disadvantages exist if the
infectious diseases physician and pharmacist do not
interact well.

Independent practice
Under a third practice model in the hospital setting,
infectious diseases physicians and pharmacists conduct
separate services: the physician handles infectious di-

Infectious Diseases Specialty Pharmacy Practice

472

seases consults, and the infectious diseases pharmacist

identifies patients with inappropriate antimicrobial therapy and makes interventions. Under this system, the
Pharmacy and Therapeutics Committee will ideally grant
the pharmacist some authority to automatically order
modifications in therapy. This model is used when
infectious diseases physicians are either unwilling or
unable to become involved in interventions concerning
antimicrobial therapy. A potential disadvantage is the
perceived competition between infectious diseases
physicians and pharmacists for consults. Indeed, the Infectious Diseases Society of America (IDSA) has issued a
statement condemning the independent practice of a
pharmacist to advise physicians on selection of antimicrobial therapy.[21 In hospitals that have limited or no
infectious diseases physician presence, this model may be
the only viable option.

the spectrum of therapy based on culture and susceptibility report^)'^-^] and intravenous-to-oral conversion of
antibiotics[73s1have shown that interventions by pharmacists can reduce costs and lengths of stay without adversely effecting quality of patient care. However, more
research and publications are necessary to fully document the beneficial impact of infectious diseases pharmacist interventions.

MATERIALS USED BY INFECTIOUS

Journals
A number of published journals specifically directed
toward infectious diseases and antimicrobial therapy are
available as resources for infectious diseases pharmacists:

utpatient Settin
As mentioned previously, some infectious diseases
pharmacists have established effective clinical practices
in the outpatient setting. The most common example of
this is the presence of a pharmacist in an HIV clinic. The
myriad of antimicrobial drug interactions and adverse
effects associated with antiretroviral therapy, the need to
periodically assess antiretroviral efficacy, and the considerable potential for noncompliance literally necessitate
the need for a pharmacist in any established HIV clinic.
Infectious diseases pharmacists work with infectious
diseases andlor immunology physicians. Pharmacists conduct medication histories and answer drug information
questions. In some settings, they may act under protocol
to assess patient response to antiretroviral therapy based
on virologic and immunologic measures, and to make
appropriate modifications in therapy.

ECT
ON

ISEASES
T CARE

The original published reports of the impact of infectious

diseases pharmacists interventions on patient outcomes
were limited to therapeutic drug monitoring of aminoglycosides. Therapeutic drug monitoring of aminoglycosides
by pharmacists resulted in more appropriate utilization of
serum aminoglycoside concentrations, more serum concentrations within the therapeutic range, and reduced
nephrotoxicity when compared with monitoring by physicians (Destache et al.).[31
Subsequent reports of the impact of interventions by
infectious diseases pharmacists have focused more on
improving the antimicrobial therapy process. Specifically, reports of antibiotic streamlining (narrowing

Clinical Infectious Diseases-This

journal, formerly
named Reviews of Infectious Diseases, is an official
publication of the IDSA. Articles are primarily directed
at the diagnosis and treatment of infectious diseases,
including clinical trials. Frequently, State of the Art
articles are published that summarize current therapy of
a particular infection. In addition, IDSA guidelines for
the treatment of infectious diseases are published in
this journal.
The Journal of Infectious Diseases-This journal is also
published by IDSA. The contents of this journal are
generally directed at the cellular mechanisms of pathogenesis and immunity of infection. From a pharmacist
practitioner standpoint, it is of less usefulness than
Clinical Infectious Diseases.
Antimicrobial Agents and Chemotherapy-One
of the
official journals of the American Society for Microbiology, this journal focuses on characterizing and quantifying the activity of antimicrobial agents against various pathogens. Many papers are directed at mechanisms
for antimicrobial resistance and activity of newer antimicrobials in vitro. Studies of the efficacy of antimicrobials, as measured via in vitro pharmacokinetic and
animal infection models, are published frequently. Studies of drug treatment in humans are also published, but
less frequently.
Journal of Antimicrobial Chemotherapy-This
British
publication addresses all aspects of infectious diseases
pharmacotherapy and therapeutics. Both American and
European authors contribute to this journal. A review
article at the beginning of each issue addresses a pertinent
clinical issue. Supplements are published regularly that

299

Drug Samples

17.
18.

19.

20.

21.

22.
23.

tions: Safe management is a difficult but necessary process. ISMP Medication Safety Alert! 1999, 4 (14), 1.
Dill, J.L.; Generali, J.A. Medication sample labeling practices. Am. J. Health-Syst. Pharm. 2000, 57, 2087 2090.
Westfall, J.M.; McCahe, J.; Nicholas, R.A. Personal use of
drug samples by physicians and office staff. JAMA, J. Am.
Med. Assoc. 1997, 278 (2). 141 -143.
Timaye, A.P.; Paauw, D.S. Personal use of drug samples
by physicians and office staff [letter]. JAMA, J. Am. Med.
ASKC. 1997, 278 (19), 1568-1569.
Tong, K.L.; Lien, C.Y. Do pharmaceutical representatives
misuse their drug samples? Can. Fam. Physician 1995. 41,
1363- 1366.
O'Young, T.; HaAet, T.K. Removal of drug samples from
two teaching institutions. Am. J. Health-Syst. Pharm. 200
57, 117% 1180.
Donohoe, M.T.; Matthews, H. Wasted paper in pharmaceutical samples. N. Engl. J. Med. 1999,340 (20). 1600.
Pai, M.P.; Graci, D.M.; Bertino, J.S., Jr. Waste generation
of drug product samples verses prescriptions obtained
through pharmacy dispensing. Pharmacotherapy 2000, 20
( 9 , 593 59s.

24.

25.
26.

27.
28.

29.

30.

Storrs, F.J. Drug samples. A conflict of interest? Arch.

Dermatol. 1988, 124. 1283- 1285.
Sigmon, J.L.; Anastasio, G.D. Drug sample closet. J. Fam.
Pract. 1992, 34, 262- 263.
MeSherry, T.J.; Tonnies, F.E. Dispcnsing medication
samples by the pharmacist in an institutional setting. J.
Am. Coll. Health 1992, 40, 136-235.
Erickson, S.H.; Cullison, S. Closing thc sample closet.
Fam. Pract. Manag. 1995. 43 47.
STFM Group on the Pharmaceutical Industry in Family
Medicine. Guidelines ,for Residency Program Relationships with Phnrmaceutical and Other Proprirtarj Cornpanie.~;Society of Teachers of Family Medicine: Kansas
City, Missouri, 1994.
Pharmaceutical Research and Manufacturers of America.
Directory of Prescription Drug Patient Assistance Progi-urns; Available at: http://www,phrina.org/searchcures/
dpdpap/ (accessed January 8, 2001).
Prutting, S.M.; Cerveny, J.D.; MacFarlane, L.L.; Wiley,
M.K. An interdisciplinary effort to help patients with limited prescription drug benefit afford their medication.
South. Med. J. 1998, 91 (9), 815--820.

PHARMACY PRACTICE ISSUES

ink

American College of Clinical Pharmacy

Kansas City, Missouri, U.S.A.

The objectives of this effort were to summarize and critique original economic assessments of clinical pharmacy
services published from 1988-1995, and to make recommendations for future work in this area. A literature search
was conducted to identify articles that were then blinded
and randomly assigned to reviewers to confirm inclusion,
abstract information, and assess the quality of study design. The 104 articles fell into four main categories based
on type of service described: disease state management
(4%), general pharmacotherapeutic monitoring (36%),
pharmacokinetic monitoring scrvices (13 % ) , and targeted
drug programs (47%). Articles were categorized by type
of evaluation; 35% were considered outcome analyses,
32% outcome descriptions, and 18% full economic analyses. A majority (89%) of thc studies reviewed described
positive financial benefits from the clinical services evaluated; hk>wever, many (68%) did not include the input
costs of providing the clinical service as part of the evaluation. Studies that were well conducted were most likely
to demonstrate positive results. Commonly, results wcre
expressed as net savings or costs avoided for a given time
period or per patient. Seven studies expressed results as a
benefit : cost ratio (these ranged from 1.08 : 1 to 75.84 : 1,
mean 16.70 : I ) . Overall, this body of literature contains a
wealth of information pertinent to the value of the clinical
practice of pharmacy. Future economic evaluations of
clinical pharmacy services should incorporate sound
study design and evaluate practice in alternative settings.
In 1989, the American College of Clinical Pharmacy
(ACCP) published a position statement entitled Prospectus on thc Economic Value of Clinical Pharmacy
Services. The document summarized literature published prior to 1988 that supported the economic value
of clinical pharmacy services and as such provided a
resource to the profession in efforts to advance the clinical practice of pharmacy. A similar review was pubCopyright

I996 by the American College of Clinical pharmacy

Encyclopediu of Cliniccil Plmrmar:y

DOI: 10.1081/E-ECP 120006412
Published 2003 by Marcel Dekker, Inc. All rights reserved.

lished in 1986. These papers have proved to be

valuable indexes of the literature and have becn referred
to by many in the profession on points pertinent to the
economic value of clinical pharmacy.
In the time that has passed since thc original ACCP
prospectus, the literature has continued to grow in both
depth and breadth of evidence supportive of the financial
justification of clinical pharmacy services. New service
models and philosophies of practice have developed in the
past 6 ycars, the most notable being that of pharmaceutical care. In addition, our ability to evaluate scientifically and measure the impact of clinical services on
costs and outcomes has matured with the incrcased understanding and use of analytical techniques in health
economics and p h a r m a c o e c ~ n o m i c s . ~The
~ ~ ] effect of
these advances on the quality and quantity of literature is
unknown. The ACCP Board of Regents thus asked the
ACCP Publications Committee to update this prospectus.
The committee reviewed, summarized, and critiqued
the literature publishcd between January 1988 and
December 1995 that included original economic assessment of clinical pharmacy services or programs, thereby
serving to update the original position statement of
ACCP. Further intentions were to provide a barometer
of the degree to which accepted techniques of economic
analysis have been incorporated into this literature, and to
make recommendations for future work in this area.

METHODS
A search of two major data bases (MEDLINE, International Pharmaceutical Abstracts) was conducted to
identify articles publishcd between January 1988 and
December 1995. The beginning date of January 1988 was
selected because the original ACCP prospectus was
inclusive through December 1987. Both MeSH and free
text search terms were used to identify English language
articles assessing the value of clinical pharmacy services.
Search terms were clinical pharmacy services, pharmacy
301

302

Economic Evaluations of Clinical Pharmacy Services (ACCP)

services, program, economic evaluation, cost justification,

cost, cost effectiveness, cost-benefit, cost analysis, costconsequence analysis, and cost-utility analysis. Review
articles, editorials, and other unoriginal reports were
excluded from the search. All citations identified were
screened for inclusion by review of titles and abstracts.
Those articles for which abstracts were not available from
the computerized databases were collected manually and
screened for inclusion.
Inclusion criteria were English language, original
evaluation, publication between January 1988 and December 1995 inclusive, assessment of a clinical pharmacy
service (defined as patient-level interaction, and not
including policy-type interventions unless accompanied
by a patient-level interaction), and some economic assessment. Exclusion criteria were reviews, editorials, and
letters, and studies published in abstract form only. All
papers suspected of meeting the inclusion criteria were
submitted to full review. In addition, the authors examined
personal files, and a secondary search of the titles of
articles cited in papers meeting the inclusion criteria was
conducted. Papers identified through this search were
again collected and screened for inclusion, and added to
the set of papers subjected to full review.
In the full review process, a modified block randomization scheme was used to confirm inclusion and to abstract information and assess the quality of each article.
Each paper was randomly assigned to two of four reviewers. Reviewers were blinded to original authors
names, affiliations, and journal of publication. Reviews
were recorded on a standard case report form and entered
into a database for analysis. Discrepancies between reviewers were arbitrated by group consensus. Reviewers
first made a final check of inclusion and exclusion criteria
to exclude further any nonapplicable articles. Reviewers
recorded the study setting, objectives, methods, results,
and any additional comments.

Each article was assessed for the type of evaluation

and categorized (Table 1). Two factors were considered in
determining the type of evaluation: the presence of two or
more alternatives, and the consideration of both input
(costs) and outcomes. Evaluations that included two or
more alternatives (i.e., concurrent control group, historical control, preintervention and postintervention design)
were considered true analyses, whereas those that did not
include a comparison were labeled descriptions. A description of the type of analysis was assigned to the
evaluation and included the options of cost or outcome
description, cost or outcome analysis, cost and outcome
description, and true clinical economic evaluation. Those
articles considered true clinical economic evaluations
were subcategorized by type, options including costminimization analysis, cost-benefit analysis, cost-effectiveness analysis, and cost-utility analysis.[61
Descriptive statistics were used to profile and characterize the articles within each data field abstracted by
the reviewers, including the type of clinical service performed, the site of the study or evaluation, and the type of
analysis performed.

ESULTS
The results of the search and screen process used are
illustrated in Fig. 1. A total of 575 articles were found
through the original search. A preliminary review of the
abstracts of these articles identified 444 that did not
involve the justification of clinical pharmacy services,
and these were deleted from the set. Seven articles were
added from the files of the authors, and 46 were identified
through the secondary search of the articles found. Thus,
184 articles were subjected to full review. During full
review, an additional 80 articles were found that did not
meet the inclusion criteria: 44 did not review a clinical

Table 1 Criteria for assessing type of analysis

Were both cost and outcomes considered?

Were two or more

alternatives considered?

No
Yes

No

Yes

Cost description or
outcome description
Cost analysis or
outcome analysis

Cost and outcome description

True clinical economic analysis
Subcategories
Cost-minimization analysis
Cost-benefit analysis
Cost-effectiveness analysis
Cost-utility analysis
~

(Adapted from Ref. [6].)

~~~

303

Economic Evaluations of Clinical Pharmacy Services (ACCP)

Primary search
(n = 575)

I
Articles
pulled for
further
review

Excluded following review

of title and abstract
(n = 444)

______>

Secondary search of citations

added to full group
(n = 46)

(n = 131)

I
*).

Author files searched and

*).

Articles excluded after

full review
(n = 80)

Articles submitted to
full review
(" = 184)

Final group described

in review
( n = 104)

Fig. 1 Literature search method and results.

pharmacy service, 20 did not describe original work, and

16 failed on both points. An analysis of the final set of
104 articles is shown in Appendix l."-llO1
Articles are sorted in Appendix 1 by the type of
clinical pharmacy service described in the evaluation.
Four major categories were used in grouping articles by
type of clinical pharmacy service: 1) disease state management, defined as clinical pharmacy services primarily
directed at patients with a specific disease state or diagnosis; for example, a renal dosing program; 2) general
pharmacotherapeutic monitoring, defined as clinical pharmacy services that encompass a broad range of activities
based primarily on the needs of a geographically assigned
group of patients; services provided may include patient
drug regimen review, adverse drug reaction monitoring,
drug interaction assessment, formulary compliance, or
rounding with physicians; 3) pharmacokinetic monitoring
services, defined as clinical pharmacy services that primarily involve evaluation of anticipated or actual serum
drug concentrations and provision of subsequent dosing
recommendations: and 4) targeted drug programs, defined
as clinical pharmacy services that are primarily focused
on a single drug or class of drugs and include predefined
guidelines for provision of alternative therapy or dosing
recommendations; for example, recommended switch

from intravenous to oral administration of histamine*receptor antagonists (H2RAs). Because of the number of
articles describing targeted drug programs, those articles
are further subcategorized in Appendix 1 based on the
class of drug involved.
Provided in Appendix 1 are the following data for
each article: 1) reference number; 2) the setting in which
the evaluation was conducted; 3) a summary of the primary intent or objective; 4) a description of the analytical method of the evaluation; 5 ) number and type of
alternatives included in the evaluation; 6) input cost
components included in the evaluation; 7) outcomes
evaluated; 8) a summary of the main results of the evaluation; and 9) miscellaneous comments about the evaluation made by the reviewer.
Articles from pharmacy-based journals dominated the
set of articles. The most common journal source was the
American Journal of Health-System Pharmacy ( n = 32,
30%). DICPIAnnals of Pharmacotherapy, Hospital Pharmacy, and Hospital Formulary were also common ( n = 19,
n = 15, and n = 7, respectively). Several foreign journals
also provided articles.
The most common type of pharmacy service was targeted drug programs (n=49, 47%). The specific drug
classes described in targeted drug programs were most
likely to be antimicrobials ( n = 2 7 ) or H2RAs ( n = 17).
Articles classified as general pharmacotherapeutic monitoring made up 36% ( n= 38), pharmacokinetic monitoring services 13% ( n = 13), and disease state management
4% ( n = 4).
Table 2 summarizes the settings of the studies included
in this evaluation. The settings of most studies were university or community hospitals (n=33 and n=25, respectively). University-affiliated community hospitals and
government hospitals were also common ( n = 12 and
n = 10, respectively). Less common settings were ambu-

Table 2 Settings of cost-justification studies

Setting

University hospital
Community hospital
University-affiliated teaching
community hospital
Government hospital
University-affiliated ambulatory clinic
Government-affiliated ambulatory clinic
Health maintenance organization clinic
Multicenter. multisite
Community pharmacy
University-affiliated government hospital

Number of studies
33
25
12
10

8
5

4
3
2
2

Economic Evaluations of Clinical Pharmacy Services (ACCP)

304

Table 3 Analytic methods of cost-justification studiesa

Method
Outcome analysis
Outcome description
Economic analysis
Cost and outcome description
Cost analysis
Cost description

Number of studies

37
33
19
13
1
1

aRefer to Table 1 for classification analysis

latory clinics of various affiliations, health maintenance

organizations, and community pharmacies.
Table 3 summarizes the analytic methods used in the
included articles. Although 19 (18%) articles were considered full economic analyses (by definition, considering two or more alternatives and measurement of both
input costs and outcomes), most were less rigorous. The
most common types of studies were outcome analyses
( n = 3 7 , 3 5 % ) , which considered two or more alternatives but excluded consideration of the costs of providing the service, and outcome descriptions ( n = 33,
32%), which failed to consider two or more alternatives
and did not consider the cost of providing the service.
The study design of the included articles was further
analyzed by individually considering the use of a comparison group (alternative) and by the types of input
costs and outcomes measured. Sixty-one (59%) studies
included a comparison group, whereas 43 (41%) did not
and were therefore considered to be descriptive. The
study designs used in papers that had a comparison group
were a concurrent control group (n=21), a historical
control group ( n = lo), and preintervention and postintervention groups ( n = 30). Precontrols and postcontrols
were differentiated from historical control designs in the
temporal relationship to the intervention. If a study compared measurements taken immediately prior to an intervention and immediately after, it was coded as a prel
post design. If a longer period of time elapsed between
comparison groups (e.g., comparing data from the study
period to the same month 1 year earlier), it was defined as
a historical control.
Seventy-one studies (68%) did not evaluate the cost of
providing the clinical service as part of the economic
evaluation of that service. Most commonly, costs were
considered as an outcome or consequence of the service
(i.e., as in drug costs avoided) rather than as an input (i.e.,
as in the investment required to establish and maintain the
program under study). Of the 33 (32%) studies that did
consider some input costs, the most common cost assessed was personnel ( n = 25). In these cases, the costs of
the program under study were quantified in terms of sa-

lary andlor benefits associated with providing the program or service. Some studies used charges (i.e., hospital
room, emergency room) rather than true costs.
Outcomes or consequences of the services described
were considered in all the articles. The most common
(12 = 80, 77%) outcome measured was drug costs avoided
(i.e., the impact of the program on reducing use or cost
of a particular drug). Other nonfinancial outcomes were
also measured. including length of hospital stay (n = 14,
13%), use of nonpharmaceutical resources. rates of adverse drug reactions, frequency of pharmacist-driven
therapeutic interventions, and qualitative changes in prescribing patterns. True clinical patient outcomes were
considered in few studies.
Ninety-three (89%) of the articles described beneficial
financial impact of the clinical pharmacy service described. Many provided either gross cost savings or, in
those that did consider input costs, net savings. Of the 33
studies that considered input costs, 31 (94%) demonstrated positive findings. Results of these were presented a
number of different ways (Table 4).
Commonly these articles expressed net savings on an
annual basis or for the time period of the study. For
example, a study in 1992 described annual net cost savings of $221,056 for clinical pharmacy services provided
in an ambulatory care clinic.'251 It did not, however, include a control group. In other cases, savings were expressed per patient admission or per patient-day. In 1993,
a well-conducted and controlled evaluation described an
average net savings of $377 per patient admission as a
result of clinical pharmacists assigned to selected inpatient medical service^."^]
In seven articles, results were expressed as benefit: cost
ratios. They differed in type of clinical pharmacy service,
site of provision of service, and resources invested in the
service (Table 5). Nevertheless, the results were impress-

Table 4 Studies that considered input costs of

providing service
Method of expressing results
Net savings annualized or
for time period of study
Net savingdpatient-day
or patient admission
Benefit : cost ratio
Other

Referencesa

[8,9,11,18.20,24,25.31,36,
45,51,53.55,68,79.82,91,
94,98,104,110]
[13- 15,20,38,52,60,71]
[ 11,14,15,41,51,60,98],
[10,291

aReferences may be listed more than once if results were expressed in

different formats.

Economic Evaluations of Clinical Pharmacy Services (ACCP)

305

Table 5 Studies allowing calculation of benefit:cost ratio

University hospital"

Pharmacotherapeutic monitoring

Government ho~pital"~]

Pharmacotherapeutic monitoring

HMO clinic['51

Pharmacotherapeutic monitoring

University hospital[411

Pharmacotherapeutic monitoring

University-affiliated[j"
community hospital

Pharmacokinetic monitoring

University hospital[601

Pharmacokinetic monitoring

HMO clinic[981

Target drug program

To examine cost benefit of clinical

pharmacy intervention and
documentation system
To study effect of clinical RPh
on health care outcomes
To measure impact of pharmaceutical
services on overall health care costs
and to estimate RPh productivity
To evaluate impact of clinical
pharmacy service on hospital costs
using cost-benefit analysis
To determine cost benefit of
pharmacokinetic services for
patients receiving aminoglycosides
To evaluate impact of computer-assisted
aminoglycoside dosing
To evaluate impact of clinical RPh
intervention program on cost of
H2RA therapy

1.98:l

6.03:1
3.2:l

1.08:l and 1.59:l

75.84:l and 52.25:l

4.09:1
4.3:1

HMO, health maintenance organization; HzRA, histaminez-receptor antagonist.

ively positive, with calculated benefits to cost ranging

from 1.08 : 1 to 75.84: 1 (mean 16.70: 1).

DlSCUSSlON
Assessment of the Literature
The conclusions drawn from our review and evaluation of
literature assessing the economic value of clinical
pharmacy services published from 1988-1995 are multifocal. The total number of articles published on this
topic has grown, as demonstrated by the number in this
review (104, average 13/yr) versus the original prospectus
(58, average 4/yr), which included articles published from
1974-1987. Although the number of published articles on
this topic appears sufficient, an opportunity does exist for
improvement in the quality of study design.
A large percentage (41%) of the articles we reviewed
did not include a comparison group. They did not incorporate a study design that would allow one to control
variance, which therefore makes it difficult for the reader
to confirm the validity or extrapolate the results to other
practice settings. This is not to say that these articles are
without value, however. Many are excellent descriptive
reports that provide insight and experience from which
others may learn.
Sixty-eight percent of studies did not consider the costs
associated with providing clinical pharmacy services as a

factor in the economic evaluation or justification of that

service, thus making it difficult to demonstrate true economic justification of the service. For those studies that
did consider some input costs, personnel costs were often
singularly included, with nonlabor costs (i.e., overhead)
being omitted. Furthermore, when charges were used,
they were often misinterpreted as costs.
The outcomes measured tended to focus on financial
consequences and not to include clinical or patient consequences. Without consideration of clinical outcomes, or
without being able to make an assumption that clinical
outcomes are unchanged, the true economic impact of the
services studied could not be proved.
Despite the limitations of many of the articles as true
economic evaluations, this literature contains a wealth of
information pertinent to the clinical practice of pharmacy
that serves to document innovative and successful experiences and programs. Of importance, we did find that
when studies were well conducted (considered true economic evaluations), the results were likely to be favorable; that is, the studies were able to demonstrate net
savings or positive benefit : cost ratios. Because of lack
of standardization in reporting of results and variability
in study design, it is difficult to make a general statement
as to the degree of benefit derived from clinical
pharmacy services. However, we were able to abstract
calculated benefit : cost ratios from the seven applicable
studies and describe a range of value from 1.08:l to
75.84:l (mean 16.70:l). In other words, for every

306

Economic Evaluations of Clinical Pharmacy Services (ACCP)

dollar invested in clinical services, on average $16.70

was saved.
These seven studies were conducted in a variety of
practice environments-university hospitals (3), university-affiliated community hospital (l), governmental
hospital (l), and health maintenance organization clinics
(2). They evaluated a spectrum of pharmacist-delivered
services including pharmacotherapeutic monitoring (4),
pharmacokinetic monitoring (2), and targeted drug programs (1). Both of these considerations speak to what we
believe to be the broad applicability of the studies results.

Limitations
We undertook this review and evaluation with the intent
of providing the reader a resource to access original literature published assessing the economic value of clinical
pharmacy services, and to evaluate the quality of that
literature. The articles included in this review represent
only those published in standard literature. We did not
consider unpublished studies and therefore our results
may be subject to inherent publication bias (so-called
file drawer effect). We included only articles that
contained some consideration of the financial impact of
clinical pharmacy services. Certainly, many useful
articles describe and evaluate clinical pharmacy services,
but focus on nonfinancial outcomes and impact, and are
worthy of review. Finally, our review of the literature,
although intended to be systematic and thorough, may not
have captured all the published literature on this topic.

Recommendations
Having reviewed and evaluated the published literature on
the economic value of clinical pharmacy services, we
make the following recommendations to clinicians,
investigators, authors, reviewers, and journal editors:

1. Future economic evaluations should incorporate

sound methodology and study designs. Study designs should control for variance by using a
comparison group such as a historical control,
concurrent control, or pre- and postintervention
measurement.
2 . Consideration should be given to the input costs,
that is, the costs of providing the service, as part
of the economic evaluation. These costs should
include direct and indirect costs if possible.
Where charges are used, they should be appropriately labeled and interpreted as such.
3. Outcome measurements should include more than
just drug costs avoided. Nonfinancial outcomes

such as clinical patient outcomes are important

and should be part of the evaluation of any service
that affects patient care. Using a disease state
management approach rather than the targeted
drug approach to cost justification may help to
identify important outcome measurements that
should be considered.
4. The concept of opportunity costs (i.e., money spent
on one resource that cannot be spent for other
purposes) should be explored. The value of any
given service should be weighed against the possible services that might be provided. The concept
of opportunity costs becomes even more important
as health care downsizing and restructuring occur.
5. Clinical pharmacy services provided in settings
outside the traditional hospital should be included
in future economic evaluations.

CONCLUSION
It is hoped that the data summarized in this article will
assist individual pharmacists, departmental managers, and
health system administrators to document and recognize
the cost effectiveness of pharmacists clinical services.
Pharmacy practitioners should take pride in both the
quantity and strength of this literature, and feel empowered to use it to justify further expansion or refinement of
their caregiving responsibilities. Attention to our recommendations regarding the design and performance of
future economic evaluations of clinical pharmacy services
will further add to the strength of this literature and the
conclusions that may be drawn from it.

ACKNOWLEDGMENTS
Members of the 1995 and 1996 Publications Committee
of the American College of Clinical Pharmacy were Brian
Alldredge, Guy Amsden, Douglas Anderson, Edward
Bednarczyk (Chair, 1995), S. Diane Goodwin (Chair,
1996), Linda Jaber, David Knoppert, Bruce Mueller,
Michael Otto, Therese Poirier, Jay Rho, Richard Scheife,
Glen Schumock, Maureen Smythe, Wilkinson Thomas,
Dennis Thompson, Donald Uden, and Eva Vasquez.
Endorsed by the ACCP Board of Regents on August 2,
1996.
From Schumock GT, Meek PD, Ploetz, PA, Vermeulen LC. Economic evaluations of clinical pharmacy services: 1988-1995. Pharmacotherapy 1996, 16(6): 11881208, with permission of the American College of
Clinical Pharmacy.

307

Economic Evaluations of Clinical Pharmacy Services (ACCP)

Appendix 1 Evaluations of economic value of clinical pharmacy services-1988Objective

(as stated
by authors)

Setting

Disease state management

To evaluate
CH"'
impact of
benzodiazepine
guidelines
on cost and
quality of care
of patients
hospitalized for
alcohol
withdrawal

Analytic Comparison
method
group

Input costs

1995

Outcomes
included

Results measured

Comments

OA

Control
group

None

DCA, LOS

Mean drug cost

decreased from
$1008/day to
$59/day/patient;
mean ICU LOS
decreased from
4.1 to 1.1 days

Input costs not

considered

UH[']

TO

evaluate
impact of
clinical RPh
on cost
savings and
patient
outcome in
asthma clinic

CBA

Historical
control

Cost of clinic
visit offset
other savings

cost of
emergency
room visits
for asthma
exacerbation

Cost savings
$30,693 and
$68,393 between
study period and
each of two
control
periods; savings
derived from
reduction in
ER visits

Drug costs not

considered;
economic value
of clinical
outcomes
(beyond
ER visits) not
assessed; no
ratio calculated

CHLgl

To evaluate
impact of
renal function
monitoring
program,
focusing on
appropriate
dosages
of renally
eliminated agents

COD

None

Personnel
costs

DCA

Cost savings
$5040 noted,
with program
cost $2700
for labor

No control group:
clinical outcomes
not considered:
measured only
what the cost of
therapy would
have been without
intervention

UACH"']

To conduct
time and
motion analysis
of PCA
vs. i.m. analgesia
and evaluate
impact on cost
and quality of
pain control

CBA

Historical
control

Costs of drug,
RPh, and
nursing labor

LOS, cost
of ADRs,
quality of
analgesia

Quality of analgesia
increased with PCA.
but so did cost
and time required

Evaluated both
RPh and nursing
time: did not
provide ratio

None

Personnel costs DCA, type of Cost savings of

$1.98/$1 invested,
intervention
with total annual
savings $7100

General pharmacotherapeutic monitoring

UH['']
TO examine cost
COD
benefit of
clinical pharmacy
intervention and
documentation
system

Missing relevant
costs and outcomes

(Continued)

308

Economic Evaluations of Clinical Pharmacy Services (ACCP)

Appendix I

Setting

Evaluations of economic value of clinical pharmacy services-1988 - 1995 (Continued)

Objective
(as stated
Analytic Comparison
Outcomes
group
Input costs
included
Results measured
by authors)
method
OD
DCA, LOS
None
To assess the
None
Positive impact on
quality and cost
patient care,
avoidance of RPh
estimated reduced
interventions
LOS by 3.7 days
using physician
assessors

Comments
Physician reviewers
estimated reduction
in LOS resulting
from interventions

To cost justify
clinical pharmacy
service on
general surgery
team
To study effect
of clinical RPh
on health care
outcomes

COD

None

Personnel
costs

DCA, type of
intervention,
clinical impact
of intervention

Positive impact on Small sample

outcomes; net
cost avoidance of
$441.46/patient

CBA

Control
group

Personnel
costs

LOS, drug
costs/
admission

Average net
savings
$377/patient
admission;
cost : benefit
ratio 4.03 : 1

To measure impact
of pharmaceutical
services on overall
health care costs,
and to estimate RPh
productivity

COD

None

Personnel
costs,
direct costs,
overhead

Percentage of
problematic
drugs, use
of service,
DCA

Average total
cost savings
$444/patient;
cost : benefit
ratio 3.2 : 1

To evaluate clinical
RPh recommendations
on number and costs
of drugs

OD

Control
group

None

DCA

Decreased
average
monthly drug
cosupatient

Input costs not

considered

To describe program
and determine
cost savings from
clinical pharmacy
services provided in
rehabilitation clinic

OD

None

None

DCA

Reduced hospital
drug costs by
$2700 during
6-mo study

Input costs not

considered

To evaluate clinical
pharmacy services
and determine
cost savings and
justification for
additional pharmacy
staff

COD

None

Personnel
costs

DCA

Annual net
savings $25,862

To evaluate impact
of a clinical
coordinator on
costs avoided by
the institution
from clinical
clinical intervention
program

OA

Pre/post

None

DCA, NO1

Average monthly
net savings $3739
and $4644 before
and after clinical
coordinator

Control group
included

(Continued)

Economic Evaluations of Clinical Pharmacy Services (ACCP)

309

Appendix 1 Evaluations of economic value of clinical pharmacy services-1988

Setting

Objective
(as stated
by authors)

Analytic
method

Comparison
group
Input costs

- 1995

(Continued)

Outcomes
included

Results measured

Comments

To describe
interventions
made by clinical
RPh and evaluate
cost savings and
cost avoidance
impact

COD

None

Personnel
costs

DCA, NO1

Cost savings of
$69.1 lipatient-day;
annual net savings
$300,079

To compare cost
and quality of
decentralized vs.
centralized
pharmaceutical
services

OA

Pre/post

None

LOS, total
cost/admission

Decreased average
total cost/admission
by $1293; decreased
average pharmacy
cosUadmission by
$155 for
decentralized

To examine value
of clinical pharmacy
intervention
program in a
community
pharmacy setting
and determine
economic value

OD

None

None

DCA, NO1

Cost avoided of
$3.47/prescription
processed

To describe
program to
develop clinical
pharmacy staff
and determine
cost avoidance to
hospital resulting
from the service

OD

None

None

DCA

Average estimated
cost avoidance
$9306/mo over 5 yrs

To evaluate and
document impact
of clinical RPh on
costs avoided at
tertiary care
teaching hospital

COD

None

Personnel
costs

DCA

Net annualized cost

avoidance $897,350

To evaluate impact
of clinical RPh on
cost and quality of
patient care in
ambulatory care
clinics

COD

None

Personnel
costs

DCA

Net annualized cost

avoidance $221,056

Emphasized
need for
documenting
interventions

To evaluate
impact of
clinical RPh on
medical team

OD

None

None

Interventions
documented

27% of interventions
prevented serious
effects

Input costs not

considered

Input costs not

considered

(Continued)

Economic Evaluations of Clinical Pharmacy Services (ACCP)

310

Appendix 1 Evaluations of economic value of clinical pharmacy services-1988-

1995 (Continued)

Setting

Objective
(as stated
by authors)

Analytic Comparison
method
group

Input costs

Outcomes
included

esults measured

Comments

To evaluate impact
of reactive clinical
pharmacy
interventions on
cost and quality
of patient care

OD

None

None

Cost impact of 2.9% of pharmacy

interventions
interventions
prevented potential
documented
medical harm;
limited cost impact

Input costs not

considered;
physicians
assessed RPh
service,
introducing
potential bias

To evaluate daily
data collection of
decentralized
clinical pharmacy
services

OD

None

None

DCA

Total savings
$126,504 due to
2506 interventions
provided

Input costs not

considered;
clinical outcomes
not considered;
no comparative
group used to
assess cost
and outcome
difference

CBA

Control
group

Personnel
costs

cost
avoidance
due to
reduced
number of
prescriptions

Cost avoidance
$4.63 for
intervention
group vs. $1.10
in control group;
savings in
prescription filling
labor noted; labor
costs associated
with program
offset by DCA

Clinical outcomes
not considered; no
ratio presented

OD

None

None

cost
avoidance
in drug and
laboratory
use

$19,000 in cost
reduction for
interventions.
184 patients;
documented
clinical outcomes
after interventions

Discussed cost
of personnel
required for
program, but did
not factor cost
into analysis; no
comparison group
for analysis

GAAC[311 To evaluate impact

(VA)
of clinical RPh on
cost and quality
of patient care

CBA

Pre/post

Costs
DCA
associated
with program
and dispensing
prescriptions
generated in
the clinic

Total cost decrease

of $22,241 during
study period

Charts assessed
for quality based
on the rate of
suggestion
implementation,
but actual patient
outcomes not
assessed

UACH[321 To evaluate cost

impact of clinical
RPh in intensive
care unit

COD

None

Personnel
costs

Cost savings
$10,010 (Canadian)
documented over
3-mo study period;
cost:benefit
ratio 4 : 1

No control group;
measured only
what the cost
of therapy would
have been without
intervention

GAAC[291 To evaluate
impact of clinical
RPhs interventions
on physician
prescribing and
costs in an
ambulatory clinic

UAAC[]

To evaluate impact
of ambulatory
clinical pharmacy
program and to
justify personnel
for the program

DCA

(Continued)

Economic Evaluations of Clinical Pharmacy Services (ACCP)

311

ADwendix 1 Evaluations of economic value of clinical oharmacv services-1988

Setting

Objective
(as stated
by authors)

Analytic
method

Comparison
group

Input costs

- 1995

Outcomes
included

iContinued)

Results measured

Comments

To evaluate
impact of
pharmacy
faculty providing
clinical pharmacy
interventions on
drug costs and
pharmacy
department
revenue

OD

None

None

DCA and
service
revenue
generated

Impact of 278
interventions
evaluated.
demonstrating
drug cost
avoidance
$1661, generation
of $6000 in
revenue from
pharmacokinetic
consultations

No control group;
measured only
what the cost of
therapy would
have been without
intervention

To evaluate
impact of
clinical RPh on
drug prescribing
and cost savings

CBA

Control
group

Personnel
costs

DCA

Decreased total
number of
prescriptions and
associated ADRs;
total cost of
prescriptions filled
in study period
$3872 less than
during control
period; total cost
to administer
program S2250

No ratio
presented;
mentioned but
did not quantify
value of
prevented ADRs

CH[35]

To evaluate
impact of
documentation
system for
clinical pharmacy
services

OD

None

None

DCA

Cost avoidance
ranged $2341 $7762/quarter
during study

Input costs not

considered; no
control group;
clinical outcomes
not considered

~ ~ " 6 1

To evaluate cost
impact of
implementing
clinical pharmacy
services in
intensive care
unit

COD

None

Personnel
costs

DCA

During 32 days,
cost avoidance
$1651, labor cost
associated with
program was
$2599

To evaluate
acceptance and
cost savings
resulting from
2-yr
postbaccalaureate
PharmD student
interventions

OD

None

None

NOI, DCA,
laboratory
cost
avoidance

Estimated annual
drug savings
$3891

No control group;
clinical outcomes
not considered;
small sample size
(number of pilot
days assessed,
and short
period of
timeiday)
Input costs not
considered

(Continued)

Economic Evaluations of Clinical Pharmacy Services (ACCP)

312

Appendix 1 Evaluations of economic value of clinical pharmacy services-1988

Setting

Objective
(as stated
by authors)

Analytic
method

Comparison
group

Input costs

- 1995

(Continued)

0utcomes
included

Results measured

Comments

To determine cost
savings of clinical
pharmacy service
in a community
hospital

CD

None

Personnel
costs

DCA

Savings of
$1,49/patient/day
for clinical
pharmacy services

Brief description
of daily
documentation
activity to
demonstrate
cost savings

To describe
impact of general
clinical pharmacy
interventions on
hospital costs

OD

None

None

Physician
acceptance,
NOI, DCA

Total savings
$15,525.81

Input costs not

considered

To evaluate
impact of
comprehensive
clinical pharmacy
services on
hospital costs
To evaluate
impact of clinical
pharmacy service
on hospital costs
using cost-benefit
analysis

OA

Prelpost

None

DCA

Net cost savings

$34.10/RPh-day

Input costs not

considered;
clinical
outcomes not
considered

CBA

Historical
control

Cost of
providing
service

DCA

Cost:benefit ratios
1.08 and 1.59 for
2 ward-based
groups

Clinical
outcomes not
considered

To determine
impact of clinical
interventions on
cost and quality
of patient care

OD

None

None

Number of
inappropriate
laboratory tests,
DCA

Annual drug cost

avoidance of
$26,580

To evaluate
impact of
PharmD student
interventions

OD

None

None

NOI, physician
acceptance

Decreased drug
costs by 50.7%

To document
interventions
of clinical RPh
in emergency
department

OA

Prelpost

None

DCA

Description of
clinical and
cost-saving
interventions

Input costs not

considered;
clinical
outcomes not
considered

To evaluate
impact of clinical
pharmacy
interventions on
cost and quality
of patient care

COD

None

Personnel
costs

Physician
acceptance,
DCA, various
quality
indicators

Annual
extrapolated
cost savings
$19,076

Documented cost
and quality using
daily patient data
collection forms

To determine
impact of clinical
RPh on cost
savings to the
hospital and
quality of
patient care

OA

Control
group

None

NOI, DCA

RPhs saved
$176,724
annually

Extrapolated
savings
from 2-wk pilot

(Continued)

Economic Evaluations of Clinical Pharmacy Services (ACCP)

313

Appendix 1 Evaluations of economic value of clinical pharmacy services-1988 - 1995 (Continued)

Setting

cp"v

Objective
(as stated
by authors)

Analytic Comparison
method
group

Input costs

Outcomes
included

Results measured

Comments

To evaluate
cost savings to
pharmacy from
interventions of
community RPh

OD

None

None

Assessment of
value of RPh
interventions,
cost of medical
care avoided

Value of avoided
care was $122.98/
intervention: $2.32
savings/prescription
screened

UAAC[481 To evaluate
impact of
clinical RPh on
cost and quality
of patient care

OD

None

None

Physician
acceptance,
patient outcome
indicators, DCA

205 interventions
made during 6-mo
study: 80.9% made
to increase quality:
18.1% to increase
quality and
decrease cost

None

None

Unnecessary
samples,
patient charges

Charge avoidance
$500,000 annually

Input costs not

considered;
charges vs. costs

DCA, number
of drug assays

Increased number
of drug levels
ordered; decrease
of $599 in
hospital costs

Increased
rational
ordering of
serum drug
concentrations

Pharmacokinetic monitoring service

To determine effect
OD
of TDM program
on inappropriate
sampling times
To evaluate
impact of
educational
efforts on use
of SDCs

OA

Pre/post

None

To determine
cost benefit of
pharmacokinetic
services for
patients receiving
aminoglycosides

CBA

Control
group

Variable costs, LOS, clinical

personnel costs, response
fixed costs

Decreased LOS:
decreased duration
of febrile period:
benefit:cost ratio
75.84:l and
52.25: 1

To determine
physician
acceptance and
impact of clinical
pharmacokinetic
recommendations
on cost and quality
of patient care

CBA

Control
group

Variable costs, Acceptance by

personnel costs, physicians,
LOS, DCA,
fixed costs
clinical response

Decreased LOS;
decreased febrile
period; decreased
direct costs; cost
of service
$85/patient

To evaluate impact
of clinical
pharmacokinetic
service on cost
and quality of
patient care
To evaluate
costs associated
with clinical
pharmacokinetic
dosing service

CBA

Control
group

Variable costs,
fixed costs

LOS, clinical
response,
patient charges

Decreased length
of treatment;
decreased LOS;
annual cost
savings $113,934

Used charges
rather than costs

OA

Pre/post

None

LOS, DCA

Cost reduction
$107,000
associated with
decrease in LOS:
reduction of
$14,000 in drug
costs associated
with program

Mentioned but
did not value
cost of system

(Continued)

Economic Evaluations of Clinical Pharmacy Services (ACCP)

314

Append~x1 Evaluations of economic value of clinical pharmacy services-1988 - 1995 (Continued)

Objective
(as stated
by authors)

Analytic
method

Comparison
group

CBA

Historical
control

Personnel
costs

cost of
laboratory
testing avoided

Increased
appropriateness
of serum drug
concentration
determination;
cost of $1000
with savings of
$3000

Clinical
outcomes not
considered; no
ratio presented

U H [ ~ TO
~ ~evaluate impact
of pediatric
pharmacokinetic
service using
guidelines as basis
for appropriate
monitoring

CA

Control
group

None

Costs avoided
through decrease
in inappropriate
monitoring

Annual cost
avoidance
$12,325 based
on fewer
inappropriate
laboratory
assays

Input costs not

considered

CHL571 To evaluate
effectiveness of
serum digoxin
concentration
monitoring, and
determine cost
impact of service

OD

None

None

NOI, timing of
digoxin serum
concentrations,
laboratory costs
avoided

Decreased
number
of digoxin
serum drug
concentrations
ordered

Input costs not

considered

OA

Control
group

None

Number and cost

of drug assays,
LOS and
readmission rate

Overall cost
savings after
1 yr of program
$100.00

Charges vs. costs

UH591 To evaluate impact

of therapeutic drug
monitoring program
for theophylline

OA

Control
group

None

Number and
cost of drug
assays, LOS

Equal cost of
RPh monitoring
and savings
after 1 yr

Charges vs. costs

UH[~]

CBA

Control
group

Service cost

LOS, room
charge, DCA

$13 11 savings/
patient in study
group; CBA
ratio of 4.09 : 1
in favor of
study group

Used charges
rather than
costs

OA

Control
group

None

LOS. room
charges, cost
of concomitant
drugs

Decreased LOS
of 1.96 days;
$490 savings/
patient in
study groups

Used charges
rather than
costs

PrePost

None

DCA

15% reduction
in amount of
ondansetron
dispensed
from period
before guideline
implementation

Input costs not

considered;
clinical
outcomes not
considered

Setting
UHL5

UHL5

To evaluate impact
of clinical RPh on
appropriate serum
drug concentration
ordering

To analyze need
for therapeutic
drug monitoring
program for
phenytoin

evaluate
impact of
computer-assisted
aminoglycoside
dosing

TO

CHL611 To compare RPh

vs. physician
dosing of
aminophylline

Target drug programs: Antiemetic agents

UHL6*] TO evaluate impact
OA
of prescribing
guidelines for use
of ondansetron on
drug costs

Input costs

Outcomes
included

Results measured

Comments

(Continued)

Economic Evaluations of Clinical Pharmacy Services (ACCP)

315

Appendix 1 Evaluations of economic value of clinical pharmacy services-1988

Setting

Objective
(as stated
by authors)

Analytic
method

Target drug programs: Antihypertensives

HMOC[631 To evaluate impact
OA
of clinical RPh
consultation on cost
of antihypertensive
therapy in HMO
family practice
clinic
Target drug programs: Antimicrobials
UAAC[64' To assess impact
OA
of fluconazole
guidelines and
concurrent RPh
intervention

Comparison
group
Input costs

- 1995

(Continued)

Outcomes
included

Results measured

Comments

Control
group

None

Average daily
drug costs

Decreased drug
costs of $20.61/
patient-year

Input costs not

considered

Historical
control

None

Appropriate
use, ADRs,
DCA

Annual cost
avoidance
$65,520

Input costs not

considered

To describe
experience with
program for
modifying dosing
regimens of
mezlocillin

OD

None

None

DCA

Annual cost
savings
$33,000 or
$49.47/patient

Input costs not

considered

To document cost
containment of
RPh antibiotic
streamlining
program

OD

None

None

DCA

Annual cost
savings $47,700

Input costs not

considered

To evaluate
educational and
intervention
program promoting
use of metronidazole
for antibioticassociated colitis

OD

Historical
control

None

DCA

Estimated annual
savings $38,829
based on
decreased
drug costs

Input costs not

considered;
clinical
outcomes not
considered

To evaluate impact
of therapeutic
intervention to
alter metronidazole
dosing

COD

Prelpo st

Personnel
costs

DCA

Annual savings
$28,000

Input costs
not considered

To describe antibiotic
monitoring program
and determine costs
avoided to hospital
from rational
antibiotic use

OD

None

None

DCA,
appropriateness

Total cost
avoidance
$42,512 during
study period

Input costs not

considered

To evaluate impact
of target drug
monitoring program
for clindamycin on
hospital costs

OA

Historical
control

None

DCA

Cost avoidance
$16,000 annually

Input costs not

considered

(Continued)

Economic Evaluations of Clinical Pharmacy Services (ACCP)

316

Appendix 1 Evaluations of economic value of clinical pharmacy services-1988

Objective
(as stated
by authors)

Setting

Analytic
method

Comparison
group
Input costs

- 1995 (Continued)

Outcomes
included

Results measured

Comments

To evaluate impact
of clinical RPh
monitoring on i.v.
ceftriaxone use
(conversion to
oral cefpodoxime)
To evaluate
antimicrobial
management
program and
evaluate impact
on cost and
quality of
patient care

CBA

Control
group

cost of
treatment

cost of
treatment
outcome

Cost savings
S46.0Ypatient
achieved, I-day
decrease in LOS

Input costs not

considered; small
sample

OA

Historical
control

None

DCA

Gross savings
in antibiotic
acquisition
cost $483,032/yr

Cost associated
with service
considered, but
not quantified

To evaluate cost
impact of two
DUE activities
performed by
undergraduate
pharmacy students

OD

Historical
control

None

DCA

Cefazolin dosing
modification
(q6h to q8h)
resulted in savings
of 518,000;
substitution of
metronidazole for
clindamycin saved
s21,000

Input costs not

considered;
clinical outcomes
not considered

To evaluate cost
impact of
pharmacy-based
antibiotic
optimization
program
GH[751
To evaluate impact
(State)
of RPh participating
in patient care
rounds on costs
associated with
antimicrobial
drug use
UACH[761 To evaluate
impact of clinical
RPh-based antibiotic
management
program

OA

Prelpost

None

DCA

Savings of
$12,640 realized
after program
implementation

Input costs not

considered;
clinical outcomes
not considered

OA

Pre/po st

None

DCA

Cost reduction
of $29,800
greater in study
period vs.
prestudy period

Input costs not

considered

OA

Control
group

None

Drug and
ancillary cost
avoidance

Estimated cost
savings $40,000
associated with
drug cost
avoidance and
appropriate use
of laboratory data

Input costs not

considered;
clinical outcomes
not considered

UACHK7] To evaluate impact

of renal function
monitoring program,
focusing on
appropriate dosages
of imipenem

OD

None

None

DCA

Potential to save
$1 1,500 annually
by adjusting
imipenem dosages
on basis of renal
function

Input costs not

considered; no
control group;
clinical outcomes
not considered

GHL711
(VA)

UHL7

UH[741

(Coiztiizued)

Economic Evaluations of Clinical Pharmacy Services (ACCP)

317

Appendix 1 Evaluations of economic value of clinical pharmacy services-1 988 - 1995 (Continued)

Setting

Objective
(as stated
by authors)

Analytical Comparison
method
group

Input costs

Outcomes
included

Results measured

Comments

Predicted cost
avoidance
approximately
$80,000 in control
vs. study periods,
but actual cost
reduction attributed
to program
>$200,000

Cost associated
with providing
program
mentioned but
not quantified

UACH[7X1 To evaluate cost

impact of
computerized
antibiotic
monitoring
program

OA

Historical
control

None

UH7g1

To evaluate impact
on hospital costs of
antibiotic program
using education
and antimicrobial
restriction

CBA

Prelpost

Costs of drug, LOS. infection

labor, and
frequency
program
monitoring and
implementation

Cost savings
$14,250
annually with
quality of
care remaining
constant

No ratio
presented

MC.
UH[*]

To conduct
retrospective
DUE to determine
potential cost
savings of
ceftazidime
dosage adjustment

OD

None

None

DCA

Ceftazidime
dosing in elderly
found to be in
excess of labeled
dosing because
renal function
not considered

Input costs not

considered;
clinical
outcomes
not considered

UHL8

TO evaluate impact
of clinical RPhs
intervention on
antibiotic costs

OA

Pre/post

None

LOS, DCA

Audit results 3
mo before and
after intervention
revealed $3498.40
reduction in drug
costs

UH[*]

To determine impact
of antibiotic
monitoring program

CBA

Pre/post

Cost of
printing
intervention
form

DCA

Net savings
$17,000
annually

Clinical
outcomes not
considered;
personnel costs
not considered;
no ratio
presented

UAGH[

TO evaluate impact
of compliance with
guidelines for thirdgeneration
cephalosporins

OA

Prelpost

None

Clinical and
microbiologic
indicators;
DCA

Documented
reduction of
$27,000 over
6 mo in pharmacy
expenditure for
antibiotics

Input costs not

considered

OD

None

None

Clinical and
microbiologic
indicators,
laboratory
costs, DCA

Savings $38;920
over 7 mo;
projected annual
savings $107,000

Input costs not

considered;
assumed quality
and clinical
outcome to
be equal

UACH[S41 To evaluate impact

of antimicrobial
intervention
program

DCA

(Conrinued)

Economic Evaluations of Clinical Pharmacy Services (ACCP)

318

Appendix 1 Evaluations of economic value of clinical pharmacy services-1988-

Setting

Objective
(as stated
by authors)

Analytical Comparison
method
group
Input costs

Outcomes
included

Results measured

Comments

To evaluate impact
of antibiotic policy
on hospital costs
and quality of
patient care

OA

Prelpost

None

DCA, duration
of antibiotics,
LOS, mortality

Decreased monthly
antibiotic costs by
$7600; average
savings $91,200
annually; fewer
deaths; decreased
LOS

To describe cost
savings to hospital
resulting from
clinical RPh and
nursing antibiotic
prescribing
interventions

OD

None

None

DCA, NO1

Cost avoidance
$23,993 during
study period

To describe and
evaluate dosing
intervention
program for
imipenem

OA

Prelpost

None

ADRs, DCA

Decreased number Retrospective

of seizure episodes; chart review
cost savings due to
dosage change

To evaluate impact
of concurrent
antibiotic use
program

OA

Prelpost

None

Length of
antibiotic therapy
mortality, DCA,
pharmacy cost,
nursing cost

Decreased number
of antibiotic
dosedpatient
by 24%: 32%
reduction in drug
costs

Input
costs not
considered

To conduct DUE
of prophylactic
antibiotic therapy
and determine
cost savings to
hospital

OA

Prelpost

None

DCA, number
of inappropriate
orders

Projected annual
cost savings
$25,000

Input
costs not
considered

OA

Prelpost

None

Efficacy
indicators,
ADRs. DCA

Decreased cost of
daily antibiotic
therapy in
study group

Input
costs not
considered

None

Personnel
DCA
costs, direct
costs

Cost avoidance
range $606-8668
annually

No control
group

None

Decreased hospital
costlpatient
treatment day by
33% equal to
$8053/yr

UACHr901 To evaluate impact

of antibiotic
therapeutic
interchange
program

Target drug programs: Acid-reduction therapy

CHi911
To document
COD
inappropriate use
of i.v. H2RAs and
calculate cost
avoided with oral
conversion
CH[921

1995 (Continued)

To describe and
evaluate the
development of
renal dosing
intervention strategy
for intermittent
i.v. HzRAs

OA

Prelpost

DCA

Input
costs not
considered

(Continued)

Economic Evaluations of Clinical Pharmacy Services (ACCP)

319

Appendix 1 Evaluations of economic value of clinical pharmacy services-1988 - 1995 (Continued)

Setting

Objective
(as stated
by authors)

Analytical Comparison
method
group
Input costs

To evaluate cost
savings to hospital
resulting from
clinical RPh
recommendations
for dosing i.v.
H~RAs

OA

To evaluate impact
of educational
intervention
with guideline
implementation

CBA

To evaluate
impact of
concurrent
DUE program
on costs
associated with
acid-reducing
therapy

Outcomes
included

Results measured

Comments

None

DCA

Treatment cost
decreased by
$1.27/day; annual
savings $838

Input costs not

considered;
clinical
outcomes not
considered

Prelpost

Personnel
costs

DCA

Annual cost
avoidance of
$25,000 associated
with decreased use
of acid-reducing
therapy; estimated
cost of program
$3000

Clinical
outcomes not
considered; no
ratio presented

OA

Prelpost

None

DCA; clinical
outcomes
including
antacid use and
ordering of
gastro-intestinal
tests

Cost avoidance of
$327,273 attributed
to program, with
no significant
increase in
antacid use of
number of upper
gastrointestinal
studies

Input costs not

considered

To evaluate
cost impact
of program
authorizing
clinical RPh
conversion
of drugs from
parenteral to
oral route

OA

Control
group

None

DCA

Cost avoidance
$53,950 with
decrease in length
of parenteral
therapy

Clinical
outcomes not
considered;
mentioned but
did not quantify
labor cost
associated with
program;
mentioned
but did not
calculate ratio

To evaluate impact
of guideline-based
intervention
program on
cost of H2RA
therapy

OD

None

None

DCA

Total cost
avoidance
$47,672
during first
6 mo

Input costs not

considered; no
control group;
clinical
outcomes not
considered

To evaluate impact
of clinical RPh
intervention
program on cost
of H2RA therapy

CBA

Prelpost

Personnel
costs

DCA

Annual savings
$14,600, with labor
costs of $3400;
calculated cost :
benefit ratio 4.3 : 1

Clinical
outcomes not
considered;
useful model for
justification of
program provided
outcomes
considered

Prelpost

(Conrinued)

Economic Evaluations of Clinical Pharmacy Services (ACCP)

320

Appendix 1 Evaluations of economic value of clinical pharmacy services-1988-

Setting

bjective
(as stated
by authors)

Analytical Comparison
method
group
Input costs

1995 (Continued)

Outcomes
included

Results measured

Comments

CH[99]

To elaluate cost
impact of
therapeutic
interchange
program for
H2RA therapy

OD

None

None

Drug and ancillary Estimated cost

cost avoidance
avoidance
$37,565lyr

Input costs not

considered; no
control group;
clinical outcomes
not considered;
included sunk
costs (nursing
costs associated
with additional
doses of drug)
as costs avoided

CH""]

To evaluate
impact of
therapeutic
interchange
program for
H2RA therapy

OD

None

None

DCA

Total $145,557 in
cost avoidance in
first yr of program

Input costs not

considered; no
control group;
clinical outcomes
not considered

HMOC"~']

TO evaluate
cost impact
of educational
interventions
in improving
use of H2RA
therapy

OA

Prelpost

None

DCA

Input costs not

Study group had
fewer prescriptions, considered:
clinical outcomes
less expensive
not considered;
prescriptions, and
small sample
more appropriate
(number of
prescriptions after
prescribers
educational
involved in
interventions than
intervention)
control group

OD

None

None

DCA. ADRs.
assessment of
treatment failure

Estimated annual
cost savings
$16.000: reduced
parenteral H2RA
use

UACH"021 To describe
impact of
therapeutic
interchange
program for
H2RAs on
cost and
quality of
patient care
UH['O3]

To evaluate
impact of
ranitidine i.v.
to oral
conversion
project on
cost savings
to hospital

OD

None

None

DCA

Decreased number
of days of i.v.
acid-reducing
agents: annual
savings $23,425

CH[''~]

TO

evaluate
impact of
clinical RPh
monitoring and
intervention
program on i.v.
H2RA therapy

CBA

Control
group

Personnel
costs

Number of i.v.
doses and
days of i.v. drug,
DCA

Lower mean
number of
inappropriate
doses in
study group;
projected net
annual savings
$15,766.37

Retrospective
analysis; no
evidence of
increased
treatment failure
or adverse
patient outcome

No ratio
presented

(Continued)

Economic Evaluations of Clinical Pharmacy Services (ACCP)

321

Appendix 1 Evaluations of economic value of clinical pharmacy services--1988

Objective
(as stated
by authors)

Setting

Analytical Comparison
method
group
Input costs

~~~~

(Continued)

Outcomes
included

Results measured

Comments

To conduct
prospective cost
analysis of
educational
efforts to change
inappropriate
prescribing of
H2RAs

OA

Prelpost

None

Physician
prescribing pattern,
DCA, number of
drug interactions

Savings of
$250,000
estimated for
1st yr
of program

Input costs not

considered

To evaluate impact
of i.v. to oral
switch program
for ranitidine

OA

Prelpost

None

DCA, pharmacy
preparation costs

Cost avoidance
$4214

Input costs not

considered

To evaluate impact
of H2RA program
on cost and quality
of patient care

OA

Prelpost

None

Patient outcome,
ADRs, drug
interactions. DCA

Decreased cost
but preserved
quality

Input costs not

considered

OA

Control
group

None

DCA

Greater reduction
in M A I D use in
clinic staffed by
RPh, resulted in
cost savings of
$38,776 more
than control
group

Input costs not

considered;
clinical outcomes
not considered;
data collected in
1985- 1986,
report not
published
until 1991

To describe target
DUE program and
determine impact
on drug and labor
costs

OA

Prelpost

None

DCA, NO1

Net annual
savings $18,756

Considered
personnel costs

To evaluate effect
of pharmacistmanaged
anticoagulation
clinical on
therapeutic
outcomes
and costs

CMA

Control
group

Charge for
service

Hemorrhagic
events,
thromboembolic
events, frequency
and charge for
clinic visits, ER
visits, hospital
admissions

Improved clinical
outcomes,
charge avoidance
$4073/person-year

Included clinical
outcomes, used
charges rather
than costs

Target drug programs: NSAIDs

G A A C [~O *]
TO evaluate
(VA)
impact of clinical
RPh activities in
an ambulatory
clinic

~~

- 1995

~ ~ _ _ _
~~

CA, cost analysis; CBA, cost-benefit analysis; CD, cost description: COD, cost/outcome description; CMA, cost-minimization analysis; OA, outcome
analysis; OD. outcome description; CH, community hospital; CP, community pharmacy: ER, emergency room; GAAC, government-affiliated ambulatory
clinic; GH, government hospital; HMOC, health maintenance organization clinic; MC, multicenter; MHF, mental health facility; SNF, skilled nursing
facility: UAAC, university-affiliated ambulatory clinic; UACH, university-affiliated community hospital; UAGH. university-affiliated government
hospital: UH, university hospital; DCA, drug costs avoided; DUE, drug use evaluation; NOI, number of interventions or recommendations; ADRs,
adverse drug reactions; H2RA, histamine2-receptor antagonist; ICU, intensive care unit; LOS. length of hospital stay; NSAIDs, nonsteroidal antiinflammatory drugs; RPh, pharmacist; SDC, serum drug concentration; TDM, therapeutic drug monitoring.

322

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Economic Evaluations of Clinical Pharmacy Services (ACCP)

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PHARMACY PRACTICE ISSUES

I
More than 17,000 brand and generic names for mcdications are currently approved for prescribing in North
America.' Of those 17,000 chemical entities, a surprising amount have similar dosages. Furthermore, many
names or the medications prescribed today arc spelled or
pronounced in similar ways. This can lead to a substantial
number of errors duc to the misinterpretation and/or
misuse of abbreviations, chemical names, and dosages.lZ1
A study by Lcsar el al. evaluated 696 clinically important
errors in a 63 1 -bed tertiary hospital and round that errors
of nomenclature (incorrect drug name, dosage form or
abbreviation) accounted for 13.4% of all medication errors. The authors further found that one in six errors involved the miscalculation of dosages, incorrect placement
of a decimal, incorrect unit o f measure, or an incorrect
administration rate."' Although poor transcription of a
medication order is an obvious contributing factor for
these types of errors, other factors at the point of prescribing also play a role. Lcsar et al. found that the most
common types of errors made were due to the inappropriate application of drug therapy knowledge (30%) and
the inappropriate use of knowledge regarding patient factors related to drug therapy (29.2c/c).L"
Physician order entry has been recommended as one
possible solution to help to prevent these types of medication errors.['I Initially, the goal of prescribing automation was to decrease the potential for error due to the
misinterpretation of handwritten orders. However, the capabilities o f computers used to aid in medication order
entry now exceed common word-processing duties. Newer systems have allowed clinicians to link patient data to
the prescribing process. Clinicians can use these data to
ensure that the drug dose, timing, and dosage form are
correct, while checking for drug interactions, duplicate
therapy, allcrgies, or disease-state contraindications. A
study by Hates et al. found a greater than 50% reduction
(10.7-4.86 events per 1000 patient days) in nonintercepted serious medication errors after a hospital-implemented
direct physician order entry.'"] Another study found a sig-

'

326

nificmt reduction in error\ due to allcrgies (76%) and

exce\\ivc drug dosages (78 5 % ) after implementation of a
computcmed antiinfective management program 15' Due
to the,e dnd other \tudy re\ult\, the National Patient Safety
Partnership has recommended implementation of direct
order entry strategie5 ' I '

Direct order entry, or electronic prescribing, is not limited

to the inpatient setting. Electronic prescribing encompasses all computer-driven automated processes used to write
a prescription for a patient. Within the past few years,
technological advances have allowed electronic prescribing to be performed in an ambulatory setting. This process
is executed in many ways. Early versions of electronic
prescribing devices consisted of a stand-alone computer
terminal located at fixed points in physicians' office^.'^'^'
These fixed terminals have expanded to use Internet webbased interfaces to access patient lcvcl information from a
health plan, write prescriptions, and send prescriptions to
a pharmacy to be filled.'"
More recent advances in technology made possible by
the personal digital assistant (PDA) have allowed physicians to electronically prescribe at the point of care. PDAs
are handheld computers that typically run using a Windows- or other proprietary-based platforms. These PDAs
use a touch-sensitive screen to maneuver through a menudriven prescribing process that can cxccutc a prescription
in as little as three stylus taps.L91The PDAs or other proprietary devices then upload the prescription via a network
connection or modem to be printed, faxed, or electronically transmitted to a pharmacy.

I
Electronic prescribing devices provide scvcral sources of
information to prescribers at the point of care provided to
Ericjcloywdin of C/iiiiuil I-'hnn?irxy
D01: 10. IOXl/E-ECP 120006404

Copyright 0 2003 by Marccl Dckkcr, Inc. All rights reserved.

Electronic Prescribing

patients. Depending on the level of programming sophistication, and the database links built into the prescribing
device, the clinician can access patient-specific formulary
lists, manufacturer recalled medications, and a host of
clinical references while choosing a therapy. The devices
can also be used to review any managed care disease
treatment protocols at the point of prescribing. It is also
possible for the prescriber to perform drug utilization
review (DUR) analyses to detect any possible drug-drug
interactions, therapeutic duplications, drug-disease contraindications, drug allergies, past adverse reactions, and
inappropriate dosing levels. These therapy edits are either
provided real-time or as possible problems detected upon
transmittal to the electronic prescribing vendor's server.
Finally, electronic prescribing devices allow the user to
provide informational leaflets to patients about their specific therapy.

PRESCRIPTION DESTINATION
Once the prescription has been entered, most electronic
prescribing systems allow prescribers to transmit prescriptions directly to retail or mail order pharmacies electronically or by facsimile. However, some systems use an
intermediary server to process prescriptions before sending them to a pharmacy. The limiting factor for electronic
disposition of prescriptions is the ability to receive the
data. Currently, a large percentage of pharmacies are not
web enabled, and an even larger number of pharmacies do
not operate on an electronic data interface that can speak
to a prescriber's electronic prescribing devise. The solution rapidly being accepted to reconcile these inequities is
a standard data transfer protocol called SCRIPT created
by the National Council for Prescription Drug Programs.
This standard (approved by the American National Standards Institute) has been accepted by most electronic
prescribing device companies, and is rapidly being adopted by large chain drug stores."""]
Who ultimately pays for the electronic prescribing capability is dependent on the electronic prescribing vendor.
Some companies charge prescribers a basic monthly fee
that ranges from $20-$250 per prescriber per month, depending on the level of information provided at the point
of prescribing. This fee typically includes hardware, software, network connectivity devices, upgrades, and a local
Other companies provide hardware and software free of charge to prescribers and charge a second
party for the use of the system. This second party is typically a pharmacy benefit manager or pharmacy, and the
fees range from $. 10-$.20 per prescription."']

327

ADVANTAGES

F ELECTRONIC

Electronic prescribing technology promises to bring many

benefits to the current system of prescribing. The technology promises to bring greater efficiency to the prescribing
process and reduces the likelihood of medication nomenclature errors. The following points highlight the potential
benefits of adopting an automated prescribing system:
Current, unbiased drug information and references can
be provided real-time to clinicians, including educational updates for existing or new chemical entities
and manufacture recalls of medications. This information could include recommended dosing, available
routes of administration, and patient educational materials.", l2]
Patient-specific insurance information can be provided
to prescribers at the point of care, including formulary
lists and disease protocol inf~rmation."~]
Patient-specific medical histories can be provided to
prescribers at the point of care, including last filled
medications, past adverse events, drug allergies, and
medical condition^."^]
Pharmacies and physicians will need to spend less time
contacting each other and insurance companies to
overcome formulary restrictions and problems found
upon drug utilization review, and to clarify illegible
handwriting.[ ,I4]
Physicians and pharmacists can expedite refill requests electronically rather than through person-toperson communication."]
Computers can expedite data exchange between health
care professionals who represent other parts of the patient's health care management team. The sharing of
patient data could lead to less preventable adverse drug
reactions and therapeutic duplications. The provision
of diagnosis data along with prescription information
also allows other heath care providers to check for therapy -diagnosis r n i s m a t c h e ~ . [ ~ " ~ ]
Computers can inform prescribers about lower-cost alternatives and generic availability at the time of prescribing."]

DISADVANTAGES OF ELECTRONIC
PRESCRIBING
Conversely, electronic prescribing has a few potential
disadvantages. Most of these disadvantages stem from the
potential of the technology to be used for other purposes

328

Electronic Prescribing

apart from which it was intended. The following is a

summary of potential misuses of the new technology:
The potential exists for a patients confidentiality to be
violated. Some of the companies offering electronic
prescription solutions download patient information to
a vendor-based server for DUR checks. The security of
this information and what it is used for beyond the
prescribing process creates the potential to impinge
upon the privacy of the patients medical information.
The receipt of a prescription can be subject to several
market barriers. First, the pharmacy must have the
electronic capability to receive the data. Second, the
pharmacy must accept the patients prescription drug
plan and be willing to operate under the financial
constraints imposed by the electronic prescribing
provider. Finally, the potential exists for pharmacy
benefit managers (PBMs) to use electronic prescribing
technology to route prescriptions to preferred pharmacies such as mail order companies.
Physicians will be prompted to adhere to formulary
restrictions and PBM-driven disease protocols more
frequently. As a result, evidence-based prescribing may
become more dependent on the use of appropriate
clinical knowledge by PBMs rather than health care
providers.
This technology can provide a false sense of security
concerning the clinical judgment of the software programming. The programming is limited to the data it
receives and the problems it is designed to detect. The
innate ability of clinicians to question and rationalize
is integral to the process of appropriate prescribing.
However, electronic prescribing technology will make
it easier to overlook the clinicians importance to the
process.
Theoretically, it is possible that electronic prescribing
devices will allow unimpeded access to physicians by
whoever is willing to pay for that access. Physician
detailing may become more prevalent through these
devices and could possibly be confused with unbiased
medication information.

IMPACT ON PRACTICE

OF PHARMACY

The advent of electronic prescribing will decrease pharmacists roles in many areas. In dispensing roles, pharmacists will have less responsibility for order entry, PBM
formulary management, and disease protocol adherence.
Furthermore, a large number of DUR functions will be
taken care of before the patients order is received in

the community or hospital pharmacy. However, the dispensing pharmacy may still function as a redundancy
check on these issues, continuing to act as a patient advocate to manage the appropriateness of patients drug
therapy. The pharmacist will still operate as an integral
check and balance concerning overlooked problems and
missed patient information pertinent to a patients effective drug treatment.
The functions performed by the electronic prescribing
technology will most likely lessen the technical burden of
the pharmacist, while augmenting the need for nontechnical clinical judgment. This augmentation of clinical
judgment should manifest primarily in the review of a
patients situation and pharmacotherapy plan to identify
barriers to the desired patient outcomes.[151Although the
more obvious problems will have a higher likelihood of
being addressed at the point of prescribing, the pharmacist
will still be needed to identify missed pharmaceutical
errors related to dosage route, timing, duration, frequency,
interaction, contraindication, and allergies. The main
emphases of the pharmacist will likely shift to identifying
and treating mismatched medications and indications,
drug overuse and abuse, drug-induced problems, improper
drug use, and potential medication errors.
With a decreased need for pharmacists to identify obvious problems associated with pharmaceutical therapy,
the pharmacist should be free to concentrate on patientcentered therapy issues. Pharmacists can spend more time
with patients identifying barriers that might prevent a
patient reaching an optimal outcome. Pharmacists can
then address these issues with education and proactive
adjustments in the patients therapy. The pharmacist can
concentrate more time on educating patients to better
monitor their therapy to increase the likelihood of maximal therapeutic benefit without troublesome misadventures. Furthermore, the pharmacist could concentrate on
therapeutic outreach programs such as brown bag
clinics, diabetic care clinics, and asthma screening.
In a hospital setting, pharmacists can shift their focus
away from dispensing roles, and take a more proactive
role at the point of care. Lieder reported that the implementation of physician electronic prescribing at Vanderbilt University Medical Center (VUMC) allowed pharmacists to have a greater role in the prescribing process.
Pharmacists reported that clinical evaluations were easier
with electronic records available at the touch of a key.
Pharmacists felt free to pursue other areas of need such as
cost-saving issues (e.g., intravenous to oral conversions of
medications). The technology seemed to promote the presence of pharmacists on the floors to provide drug information to other health care professionals. The VUMC
pharmacy actually maintained the electronic prescribing

329

Electronic Prescribing

$ystem and providcd educationd enhancements directed

at physician5 a9 the need for intervention, in therapeutic
areas aio\e Furthermore, the pharmacy planned to expand
its service, to include an inpatient anticoagulant management program

5.

6.
The future appears very bright for electronic prescribing.
Certainly, the upfront costs for irnplcmenting programs,
and thc refinement of hardwarc and software specifics are
important issues to resolve. However, the benefits of improved care, strcamlined workflow, and more efficient
use of clinicians timc are important enhancements that
have continued to cncourage expansion of these technologies. As wider audiences use these applications, continued
research is needed to assess the use and refinements necessary to optimally apply these important systems.

I.
8.
9.
10.
11.

12.

Institute for Safc Medication Practices. A Call fo Eliminate

Handwritten Pt-e,tcrip/ioa Within 3 Years: Institute for Safe
Medication Practices: 2000; I - 12.
Institute of Medicine. To Err Is Human; Building a Safer
H d t h System;National Academy Press: Washington, DC,
2000.
Lesar, T.S.; Briceland, L.; Stein, D.S. Factors related to
errors in medication prescribing. JAMA, J. Am. Med.
Assoc. 1997. 277 (4). 312 317.
Rates, D.W.; Leape, I,.L.; Cullen, D.J.; Laird, N.; Petersen,
L.A.; Teich, J.M.: Burdick, E.; Hickey, M.; Kleefield, S.;
Shea, B.; Vliet, M.V.; Seger, D. Effect of computerized

13.

14.

15.

16.

physician order entry and a team intervention on prcvention of serious medication errors. JAMA, J. Am. Med.
Assoc. 1998, 280 (15), 1311-1316.
Evans, R.S.; Pestotnik, S.L.; Classen, D.C.; Clernmer, T.P.;
Weaver, L.K.; Orme, J.F.; Lloyd, J.F.; Burke, J.P. A computer-assisted management program for antibiotics and
other antiinfective agents. N. Eng. J. Med. 2001. 338 (4),
232-238.
Rivkin, S. Opportunities and challenges of electronic physician prescribing technology. Med. Interface 1997, 83,
77 -83.
Sardinha, C. Electronic prescribing: The next revolution in
pharmacy? J. Managed Care Pharm. 1998. 4 ( I ) , 35 39.
Pankaskic, M.; Sullivan, J. New players, new services:
E-scripts revisited. J. Am. Pharm. Assoc. 2000, 40 (4),566.
Martin, K.D. Digital prescription pads; bad penmanship?
Essent. Inf. 2000, 2 (1), 3 4.
Ukens, C. Are you ready?Drug Top. 2001. 39; 34 36.
Staniec, D.J.; Goodspeed. D.; Stember, LA.; Schlcsinger,
M.; Schafermeycr, K., ct al. The National Council for
Prescription Drug Programs: Setting standards for electronic transmission of pharmacy data. Drug Benefit Trends
1997, I , 29-35.
Venot, A. Electronic prescribing for the elderly; will it
improve medication usage. Drugs Aging 2001, 15 (2), 77
80.
Armstrong, E.P. Electronic prescribing and monitoring are
needed tu improve drug use. Arch. Int. Med..2000, 160
(18), 2713--2714.
Komshian. S. Electronic prescribing; system helps physicians avoid errors and offer better service. Phys. Comput.
2000, 12-15.
Canaday, B.R.; Yarborough, P.C. Documenting pharmaceutical care: Creating a standard. Ann. Pharmacothcr.
1994, 28, 1292 1296.
Lieder, T.R. Computcrizcd prescriber order entry changes
pharmacists roles. Am. J. Health-Syst. Pharm. 2001, 58
(lo), 846--851.

PHARMACY PRACTICE ISSUES

Hospital Principe de Asturid, Madrid, Spain

TlON
The Encyclopedia of Bioethics defines bioethics as:
The systematic study of the moral-dimensions-including moral vision, decisions, conduct and policies-of the
life sciences and healthcare, employing a variety of
ethical methodologies in an interdisciplinary setting .
Clinical ethics is considered to be a subspecialty of
bioethics and rcfcrs to the daily dccision making of those
who care for the patient.

As emphasized by Dicgo Gracia,* thc professional

relationship between thc health professional and patient
is a social one, although it scems that no one else is
involved. When speaking of third parties, one delimits
within a generic concept of society, a more precise one. In
the professional relationship between the health professional and patient, there are three parties. The relationship is not lineal but rather triangular with three
vertices: the patient, the health prqfessional (physician,
pharmacist, or nurse), and thc society (social structures:
health institutions, health insurance, etc.).
One might think that the health professional and the
patient make, in accordance with the principles of
nonmalcficcnce and autonomy, the decisions they find to
be pertinent. The third parties put them into practice, as if
these were means or instruments to reach an end: the
health professional-patient decision. But thc third parties are structures with their own entity. So much so that
they are guided by a third principlc distinct from that of
the health professionals nonmalcficence principle and that
of the patients autonomy. The principle of the third parties or that of the society is that of justicc. The principle of justice has embodied itself in a political tradition.
Changes in the healthcare model can gcncratc ethical
conflicts. If healthcare is made univcrsal, it covers the
cntirc population. Due to economic crises and scarce
330

rewurccs, it I \ not po\slblc to meet all needs, lust the

basic one\ or those that can be legally claimed. In any
case, the system should guarantee equal acce\s to and fair
di\tribution of limited health resources

ETHICAL THEORIE
~R A MEW O R KFOR
Despite the fact that the new codes of pharmaceutical
ethicsl41 include

the basic principles upon which

bioethics is based (i.e., beneficence, autonomy, and justice), they are not complete enough to serve as a framework for making decisions in concrete situations where
the basic principles come into conflict. In this case, an
ethical foundation and a method are necessary.
The primary foundations are summed up in three
thcorics: the theory of virtue, the deontological theory,
and the consequcntialist theory. (The reader is referred to
other sources for more information.)
Biocthics, basing itself on the moral canon of the
human being and on the ncccssity, as a rational being, to
morally justify oncs own acts, adopts the four ethical
principles: autonomy and ben&cence which pertain to the
private sphere of the individual and nonmaleficence and
justice which pertain to the public sphere.

Decision- Wlakin
Clinical Ethics
For several years, dccision trees have been used in clinical
ethics, although gcncrally in a simplified form without
carriyng out a detailed calculation of probabilities. One of
the first to use this procedure was Baruch Brody, but the
model was more widely accepted due to its simplicity was
that of David C. Thomasma. Albert Jonscn developed a
procedure based on the language of cases and maxims. Sir David Ross, a great English ethicist at the
beginning of the twentieth century, established the principalist method of the analysis of concrete cases. In this
method, he establishes two moments in the moral judgment. First, that of the prima j a c i e obligations and then
Etzrqclopc4ia of Clinic a1 Phnrmucy
DO1 10 108l&,-ECP 120006385
Copyright G 2003 by Marcel Dekker, Inc All nghti reserved

331

Ethical Issues in Clinical Pharmacy

that of actual obligation-that which is a true duty in a

concrete circumstance. In other words, the prima facie
obligations are objectives that can be canceled by other
prima facie obligations of greater urgency. According to
D. Gracia, their present application consists of[61
The a priori moment: The prima facie principles of
autonomy, beneficence, nonmaleficence, and justice.
The a posteriori moment: Real and effective
principles where the prima facie principles that are
in conflict are arranged in order of importance, taking
into account the concrete situation and the foreseen
consequences. The hierarchy can vary according to
each persons perception of a concrete situation. For
this reason, it is best to keep in mind the greatest number of possible viewpoints in an attempt to enrich the
analysis as much as possible before making a decision.
Such is the primary objective of the so-called Institutional Committees of Ethics.
Professor Diego Gracia uses a procedure based on the
analysis of the principles and consequences, like that
suggested by David Ross, and applies it to clinical ethics.
Decision procedure in clinical ethicsL6]

1. Analysis of clinical history by problems (biological, social).

2. Analysis of the clinical biological data and discussion of findings.
3. Identification of possible ethical problems-differentiate, count, and define all the ethical problems found in the clinical history.
4. Selection of the problem that causes a fundamental
conflict of values.
5. Study of the possible courses of action.
6. Selection of the optimum possibility, that which
saves the most values in conflict.
7 . Decision on the course of action to be taken.
8. Analysis of the strong arguments against the decision, as well as the reasons for the decision (ability to defend it publicly).

within the framework of the relationship between health

professional and patient discussed earlier. For teaching purposes and because therapy with medication is
used on almost all patients, this relationship triangle
could be modified. It could be given a new dimension
by converting it into a tetrahedron with the relationship
physician-pharmacist-patient at the base and the society at the upper vertex (Fig. 1). Neither nursing nor the
family is being excluded, as they are included with the
physician and patient, respectively.
Professionals within the clinical relationship should
work within a legal framework that defines the domain of
each and respects the following patient rights:
Confidentiality is the obligation of all health professionals to not reveal to others, without permission of
the patient, information relative to the sick person or
the illness, which goes along with the right to
confidentiality of the patient. But this is a prima facie
obligation, not an absolute one. Thus, when another
person is in danger or the law calls for it, an exception
should be made.
Privacy, a patient right, dictates that no nonauthorized
persons have access to their room, clinical history, or
databases where pertinent information can be found.
Revealing clinical, diagnostic, therapeutic, and prognostic information to the patient, as long as legislation
does not say anything to the contrary, is in the domain
of the treating physician. This fact does not mean that
the pharmacist cannot give the patient information on
the prescribed medication. But, for the benefit of the
patient, it is best that this be done within the
framework agreed upon for the collaboration between
physician and pharmacist.

Third parties -Administration

-Insurance companies
-Judges

/r;

OBLEMS IN THE
PHARMACISTS CLINICAL PRACTICE
Relationship Between Physician,
Pharmacist, and Patient
The pharmacist, as a health professional, can become
immersed in various ethical problems. These are not
unique to the pharmacist; many health professionals must
deal with these same problems.[71 Such conflicts develop

Physician

atient

Fig. 1 Relationship between physician, pharmacist, and

patient.

Ethical Issues in Clinical Pharmacy

332

efinition of the Et

T. L. Beauchamp and J. F. Childress define an ethical

problem as a conflict between two moral obligations
or norms. In general, there are two types of ethical
problems:[s1
Those originating from doubts about the morality of
the act in itself in the face of strongly opposed
arguments.
* Those originating from doubts about the decision
whether to do one thing or another, both being mutually exclusive and implying a moral obligation.

The more specific problems in the pharmacist's clinical practice within this relationship are derivatives
of the therapy with medication, nutrition, hydration, and
placebo treatments.
We can define the ethical problem in pharmacotherapy
as the conflict between moral obligations or norms that
can put in danger the pharmacological treatment that is
best for the patient.

For this reason, as a precursor to the problem, it is

assumed that the pharmacist will maintain professional
competence, and that the pharmacist knows the clinical
history of the patient as well as the circumstances of the
case and preferably of the patient.
A conflict is generated when once the discrepancies
have been discussed with the physician, it is socially
expected that the pharmacist follow the medical order and
dispense the medication prescribed.
This type of conflict can come about in the following
circumstances:

* Omission of a validated and clearly suitable therapy.

* Prescription of nonvalidated therapies, which are considered to be neither suitable nor nonsuitable.
0
Therapies that are clearly nonsuitable.
0
The imposition of therapies on the patient on the part
of the health professionals.
* Patient demand for a therapy not recommended by the
physician.
Practical examples from scientific literature include
obligatory sedation,[" toxic analgesia,"'] the withdrawal
of treatments (antibiotics. nutrition,
and
the use of a placebo.[13]

lassification of Ethical
in ~ h a r ~ a c o t h e r a ~ y
Unavailability of medication
The ethical problems in pharmacotherapy can be classified in the following manner.
Pharmacotherapeutic decisions
These are problems brought about by interprofessional
differences (physician-pharmacist-nurse) in the making
of pharmacotherapeutic decisions:
0

In the evaluation of the benefits and risks of the

necessary pharmacotherapy or that prescribed by a
physician for a patient.
In the inclusion of patient preferences in the pharmacotherapeutic decisions.

The analysis of these problems identifies a conflict of

values or norms. On the one hand, in the first case it is the
moral obligation of the pharmacist to promote the optimum treatment for the patient. In the second case, it is
the obligation of the pharmacist to respect the autonomy
and dignity of the patient.
The most adequate therapeutic decision is the selection
of the therapeutic option that is most valid, taking into
account the patient's circumstances in view of a highly
probable diagnosis and prognosis, which is furthermore
then accepted by the patient.

This is an ethical problem brought about due to lack of

access to or unavailability of medication which is clearly
suitable, with no equally efficient alternatives for a specific patient, orphan drugs, etc.
The present availability of scientific literature to all
professionals in industrialized countries can lead to the
knowledge of the existence of medications that are not
commercially available in our countries. The professional
could feel that it is more appropriate for the patient, but
the administration does not approve its importation.
Another case would be when there is a lack of medicines in a given moment. This rationing would then imply the selection of a population to be treated, and it
would be required that clear and fair criteria be used, such
as the objective criteria of greatest benefit or due to
prognostic factors or even by drawing lots.
The analysis of this problem introduces, on the one
hand, the obligation of the pharmacist to promote the
optimum treatment for the patient, and on the other hand,
the obligation of the administration to establish explicit
criteria for access to or availability of medicines being
researched for severe illnesses or those which are lifethreatening without satisfactory alternative treatments"]
(such as policies on orphan medicines, magistral formulation of nonregistered active ingredients, etc.).

Ethical Issues in Clinical Pharmacy

A conflict can arise between the standard of evidence

considered necessary by the administration, the randomized and controlled clinical study (RCT), and the desire
of the patient to participate in an open trial, compassionated use (CU). This would mean a conflict between
the principle of autonomy (patient) and that of beneficence (administration).
In favor of the open trials CU, it is argued that a
minimum is being required (the RCT), which the patient
does not want, and thus falls into a social paternalism.
Furthermore, it is argued that the investigation of the
clinical practice is possible, carrying out studies of results, without having to do studies with a control-arm
or placebo.
In favor of RCTs, it is argued that since a vulnerable
population is being dealt with, there could be a commercial exploitation upon introducing a medication in a
pathology that does not have therapeutic alternatives,
without having obtained a minimum standard of scientific
evidence. If all of the patients with this pathology are
offered this medication, no comparison can be made
between this alternative and a placebo. Thus, there will be
no certainty of its efficacy, and no other posterior therapy
can be compared with a placebo.

Discrimination
This ethical problem is brought about due to a possible
discrimination either in the use of or the cost for the
patient of the pharmacotherapy.

Negative Discrimination in the Use of the Pharmacotherapy. This refers to the nonutilization of suitable
therapies for elderly patients or women without situations
of comorbidity which justify it."4,'51 The Committee of
Ethical and Judicial Affairs of the American Medical
Association has written reports about age-base rationing,
gender, and black- white disparities in clinical decision
making. [l6l
In reality, negative descrimination does not produce any ethical conflict. It is not ethical in itself, as
it does not respect the principles of nonmaleficence
and justice.
Positive Discrimination in the Use of or in the Cost of
the Pharmacotherapy. An example is the use of epoetin
in patients who do not accept blood transfusions for religious and other reasons. The conflictive principles in
this case could be beneficence and justice. Its use could be
justified if justice is understood as equity, using the
following argument: Blood transfusion is clearly against
the beliefs of this group. These beliefs have been repeatedly infringed upon. According to the principle of

333

equity, more should be given to the most needy, always

applying explicit and transparent criteria.
As far as cost is concerned, positive discrimination
occurs when the administration decides in favor of uublic
financing of complete therapies for certain pathologies.[171

Rationing
These ethical problems are brought about by the denial or
restriction of medicines due to cost.
Rationing according to cost is the systematic and
deliberate denial of some resources, although they could
be very beneficial, because they are considered very expensive. Those cases for which there are less expensive
alternative therapies, which are equally efficient and safe,
are excluded. This would clearly be the most just (principles of rationality and distributive justice) and suitable therapy.
Rationing of a clearly suitable therapy that does not
have an alternative that is equally efficient and safe.
The principles in conflict here would be those of nonmaleficence and justice. The rationing should be
equitable and not infringe upon the "decent minimum." This is ethically acceptable when the rationing criteria are explicit and known to those potentially
affected. This is understood within a framework of
scarce resources in which all of the measures have
been adopted for the rationalization of these.
Rationing of therapies that are thought to be neither
suitable nor nonsuitable (there is no proof for or
against) which are restricted or denied due to their
elevated cost. The conflict in this situation comes
about between the principle of beneficence (if the
physician orders the treatment) or the principle of
autonomy (the patient wants the therapy) and that of
justice. No conflict exists if the patient finances hisher
own treatment, but it does exist if it is financed by the
public health service. Generally, the principle of justice prevails over the other two, and all exceptions
should be justifiable. For decisions for rationing to be
just (distributive justice), they need to be adopted by
the Health Administration.

REFERENCES
Reich, W.T. Encyclopedia of Bioethics (CD-Rom Revised
Edition); MacMillan Library Reference: New York, 1995.
Gracia; D. La relaci6n clhica. Rev. Clin. Esp. 1992, 191
(2), 61-63.
American Pharmaceutical Association. Code of ethics for
pharmacists. Am. J. Health-Syst. Pharm. 1995, 52, 2131.

Ethical Issues in Clinical Pharmacy

334

4.
5.
6.

7.
8.

9.

10.

I I.

FIP Code of ethics 1997. www.fip.nl/publication/

publication1 .htm. (accessed Oct. 2000).
Gracia, D. Fundamentos d~ Hiolica, 1st Ed.; Eudema:
Madrid, 1989.
Beauchamp, T.L.; Childress, J.F. Principles of Biomedical
Ethics, 4th Ed.; Oxford University Press: New York,
1994.
Gracia, D. Proredimientos c>n Etica Clinica, 1st Ed.;
Eudema: Madrid, 1991.
Bucrki, R.A.; Vottero, L.D. Ethical Respon.sahility in
Pharnzary Practice; American Institute of the History of
Pharmacy: Wisconsin. Madison, 1996.
Manolakis, M.L.; Urctsky, S.D.; Veatch, R.M. Scdation of
an unruly patient. Am. J. Hosp. Pharm. 1994,51. 205-209.
van der Heide, A.; van dcr Maas, P.J.; van der Wal, G.;
Kollee, L.A. Using potencially life-shortening drugs in
neonates and infants. Crit. Care Med. 2000, 28 (7), 2595
2599.
Winker, M.A.; Flanagin, A. Caring for patients at the end
of life. JAMA 1999, 282 (20), 1965.

12. Council on Ethical and Judicial Affairs American Medical

Association. Medical futility in end-of-life carc. JAMA
1999, 281, 937-941.
13. Lachaux, B.; Placebo, L.P. Un Medicamento que Busca la
Verdad, I st Ed.; McGraw Hill: Madrid, 1989.
14. Pettersen, K.I. Age-related discrimination in the use of
fibrinolitic therapy in acute myocardial infarction in
Norway. Age and Aging 1995, 24, 198-203.
15. Miller, M.; Byington, R.; Hunninghake, D.; Pitt, B.;
Fuberg, C.D. Sex bias and underutilization of lipidlowering therapy in patients with coronary artery disease
at acadeinical medical centers in the United States and
Canada. For the Prospective Randomized Evaluations of
the Vascular Effects of Norvasc Trial (PREVENT)
Investigators. Arch. Intern. Med. 2000, 160 ( 3 ) , 343 347.
16. www.ama-assn.org/ama/pub/catcgory/25 I3.html (accessed
Oct. 2000).
17. Rothman, D.J. The rising cost of pharmaceuticals: An
ethicists perspective. Am. J. Hosp. Pharm. 1993, 50
(Suppl. 4), 10-12.

PHARMACY PKACTICE ISSUES

ica
Kansas City, Missouri, U.S.A.

IST
Biocthics is a relatively new field of study concerning the
investigation of ethical issues in medicine, health care,
and the life sciences. From the standpoint of bioethics,
clinical pharmacy research presents no novel ethical
questions; however, the type and scope of issues involved
differ from those faced by other practitioners. It is
important for pharmacists to be aware of the ethical
issues, givc thoughtful consideration to then, and be
sensitive to how they may affect their involvement in
research. The current Code of Ethics for the practice of
pharmacy virtually neglects issues encountered by pharmacists as they conduct clinical research."l
Pharmacists arc expanding their responsibilities as
health care practitioners by initiating and participating in
clinical research.121These activities range from custodian
of nonclinical and clinical trial information to principal
investigator cngagcd in original research. For a discipline to survivc as an entity, it must expand its body of
knowledge continuously, rather than relying on other
disciplines to create its knowledge base, including generating data that propose of confirm theories, principles,
or relationships.
Beca~iscof the naturc of ethics, this article presents
more questions than it provides answers; it is difficult to
predefine the right answers to ethical questions. Most
experienced investigators will recognize the circumstances described and will have developed their own
solutions. The article however, should prove useful to new
investigators or trainees, perhaps as a mechanism to
introduce discussion with mentors. It identifies ethical
issues and questions in clinical pharmacy research regarding protection of human subjects, informed consent, conflicts of interest, clinical trial design, investigator independence, and scientific integrity.

Copyright <C I993 by the American College of Clinical Pharmacy

Eizcycloprdia oj Clinical Phi-mat:).
DOI: 10.1081/E-ECP 120006406
Published 2003 by Marcel Dekkcr, Inc. All rights reserved

AL

The Nuremberg Code'"''

and the Declaration of HclsinkiL5' arc accepted international documents guiding the
conduct of human clinical research (Appendices 1 and
2). The Nuremberg Code, established in 1948 after the
war crimes trials of 1946, was the first internationally
recognized code for human research. During the early
19SOs, ethics committees lor clinical research appeared
in the United States. Until then, physician investigators
and research institutes autonomously determined when
investigations became dangerous and to what extent research subjects should be informed. Later the Department of Health, Education, and Welfare [the present
Department of Health and Human Services (DHHS)], in
response to reported abuses of the rights of individuals
participating in certain federally supported research endeavors, mandated that all protocols be screened by institutional committees responsible for the protection of
human subjects. The fedcral government committed itself
when Congress established the National Commission for
the Protection of Human Subjects of Biomedical and
Behavioral Research in 1974. The commission issued the
Belmont report in 1 978;'",7' with that, institutional review
boards (IRBs) were born and principles of protecting the
rights of human subjects participating in research began
to evolve.
The Belmont report describes the basic ethical principles that underlie research involving human subjects:
respect for persons, beneficence, and justice. The report
discusses application of informed consent, assessment of
risks and benefits, and selection of subjects. Its regulations require that IRBs have not fewer than five members
who have the capability to judge research proposals in
terms of community attitudes. Therefore, IRBs must include people whose primary concerns lie in the areas of
legal, professional, and community acceptance rather than
in the overall scientific design.
During the early 198Os, the DHHS developed and
published rules and regulations for the protection of
335

336

human research subjects participation in federally funded

research known as the Code of Federal Regulations. The
Food and Drug Administration published similar regulations governing human research and investigations that
are intended to support marketing permits for drugs, food
additives, medical devices, biologic products, and electronic devices. These sets of regulations serve as the
cornerstone for the oversight of safe human experimentation and guide all who participate in clinical research,
(e.g., IRBs, investigators, research sponsors, research
subjects). Generally, state agencies adopt the federal
standards, and local research institutions interpret and
apply them to all research activities involving humans.

PROTECTION OF HUMAN SUBJECTS

The IRB is charged, by federal, state, and local institutions with ensuring that principal investigators adequately protect the health and well-being of individuals
whose participation may cause them to be at increased
risk to hazards, defined broadly as physical, psychologic,
sociologic, and legal. Thus, it is impossible to conduct
clinical research in humans that would not affect one or
more of these areas.
If local institutions receive any federal research
money, all human research must be approved by the
IRB. This is not the basis for IRB review but provides the
incentive for local institutions to conduct studies that are
ethical. The committee becomes involved in matters such
as confidentiality, anonymity, and moral issues related to
experimental activities. Approval from an IRB, however,
does not relieve the principal investigator from the basic
responsibility of safeguarding the health and welfare of
participating individuals. This is a moral and professional
responsibility that cannot be delegated.

INFORMED CONSENT
Informed consent comprises two distinct concepts.
Informed means that the researcher provides something
(information, assistance with a decision) to the subject.
Consent means that there is something (permission) that
the researcher requests from the subject. Consent must be
given freely.
The informed consent process answers the moral
question, when is it permissible to include competent
people as research subjects? The answer is, if, and only if,
they have given their free and informed consent. Inherent
in this statement is the idea that investigators should ask
for or request consent, not simply to get or obtain it. The

Ethical Issues Related to Clinical Pharmacy Research (ACCP)

mere existence of a signed form does not guarantee that

the informed consent process worked for the benefit of the
subject, but it can facilitate the process. The rights of the
subject must be protected, and informed consent must be
requested and obtained.
A risk-benefit assessment must be performed before a
proposed investigation is submitted to the IRB. Because
the true risk-to-benefit ratio generally is unknown, clear
evidence for a favorable outcome must exist. Benefits
may be gained by individual participants or by society as
a consequence of the proposed activity.
Potential participants must agree in writing to the
conditions of the study after receiving a complete and
understandable explanation of the conditions of participation, the purpose of the activity, and the possible hazards
involved. They must have the right to ask questions and to
withdraw their consent at any stage of the activity.

Ethical Questions Concerning

Informed Consent
Informed consent assumes that accurate information is
being given, that the subject comprehends the information, and that the subject volunteers to participate. Do
investigators emphasize each aspect appropriately? For
example, how does the investigator ensure that the subject
comprehends? Examples of methods used are having the
subject repeat back in her or his own words the information immediately, and repeat it at some future time
while involved in the research; and using a witness to sign
the consent form.
While preoccupied with the informed consent form,
investigators may neglect using required and appropriate
language. How do pharmacists ensure that eighth-grade
language is used on the consent form, and is it ever
verified? If non-English-speaking people are being requested to participate in research studies, the informed
consent form should also be written and presented in
a language they understand. Computer programs and
English teachers may be used to facilitate this process.
Thus, two informed consent forms would be prepared, one
in English and one in the appropriate non-English
language. Investigators should ensure that these issues
are not neglected.
How much information is necessary for potential
subjects to be informed? Should investigators tell the
subjects how much money they are compensated per
subject recruited? It is probably unnecessary for subjects
to understand how clinical research is funded (e.g.,
overhead fees, fees for certain services), unless this
information would influence any reasonable person to
participate (or not to participate). The pharmacy profes-

Ethical Issues Related to Clinical Pharmacy Research (ACCP)

sion and society as a whole determine what reasonable

people usually do, and this is susceptible to change over
time. Research subjects have a right to know what is
known, including the views of the investigators specifically and the pharmacy and medical professions in
general. At minimum, investigators should give subjects
the information that the average reasonable person would
want to know.
Finally, how informed could a subject be about a new
chemical entity when the aim of the study is to gain
information for the first time in humans? To balance the
apparent lack of information, the investigator is responsible for carefully monitoring the subject during all stages
of the investigation.

Payment to Study Volunteers

The informed consent process raises ethical questions.
The informed consent form may state that volunteers will
be paid for their services, yet when does the payment
become simply an inducement? Payment to volunteers for
participation in drug trials is common and usually can be
subdivided into two types, reimbursement for expenses
incurred incidentally and wage payments. Reimbursement
might cover expenses such as transportation costs, costs
incurred by participation (e.g., extra blood sampling, new
drugs or devices being used), and lost work time. Wage
payments involve remuneration for services provided in
serving as a research subject. These payments could be
based on a number of factors, such as time commitment
required, nature, and number of procedures performed, or
to facilitate recruitment in a timely fashion. Payment
should not constitute an inducement.
When ill persons are offered money over and above
expenses to enter a clinical trial of a new drug therapy,
the possibility of coercion exists. The reasoning is that
if the patient is poor, they might not be able to afford
the therapy without entering the trial. Contrast this
experience with renally impaired volunteers recruited
for a pharmacokinetic study of an antibiotic. Renal
failure is not the target of therapy. The subjects receive
no therapeutic benefit from participating and are paid
as volunteers.
The IRBs should review research funding for appropriateness and possible coercion, specifically as it applies
to subject recruitment. If the amount of payment is so
high as to induce any reasonable person to participate,
regardless of the risk, it is obviously too high. It becomes
difficult, however, to determine when coercion is present
because the majority of cases are not this obvious.
Investigators should be able to justify any payment to

337

research subjects. Several factors should be considered in

justifying payment, such as the intensity of the protocol,
whether it is funded and by whom, and the degree of
benefit to subjects other than monetary.

Influence of Drug Therapy

Little information exists about how a patients drug
therapy influences the informed consent process. For
example, can a patient who has had several doses of
intravenous morphine give consent to participate in an
acute myocardial infarction protocol? Sedated patients
may not understand adequately what they are being told;
therefore, they cannot make up their minds freely. As
another example, how informed can patients be who are
experiencing blurred vision from atropine? Does drug
exposure influence continued participation or future
consent? If there are any doubts, a family member,
guardian, or patient advocate should be involved in the
informed consent process.

Adverse Effects
In the context of a clinical trial, informing the patient of
possible side effects could influence the outcome of the
study. However, subjects have the right to know what
may be expected to occur during participation. They must
be informed of all possible adverse effects consistent with
the information in the package insert (if available) and the
information known from other studies.

ETHICAL QUESTIONS C ~ N C ~ R N I ~ G
MORAL PRINCIPLES
Pharmacists, like physicians, have to be aware of the
sovereignty of the patient. Although the protection of
human subjects is critical, there is little opposition to the
protection of human rights. However, opposition to other
critical issues does exist to various degrees.

Questions of Fairness
When should we encourage repeated volunteering? Could
studying the same pool of patients have a negative impact
on the care of others? In other words, volunteering over
and over again may; 1) deny the benefit of that research to
others; 2) make research subjects bear too great a burden
themselves; and 3) result in data that cannot be general-

338

ized to the rest of the population. Careful examination of

the purposes of each investigation must be made to ensure
that repeated volunteering is beneficial to subjects or to
the experimental purpose. Thus, mere expediency of enrolling subjects does not justify studying the same individuals routinely. In some instances, such as pharmacokinetic studies, repeated use of the same subjects may
be acceptable.
Therapeutic research is intended to benefit those who
are the subjects of that research. What are the proper
criteria for inclusion and exclusion that would ensure that
everyone has a fair chance of benefiting from participating within the scope of the hypothesis being tested? The
principle of justice or fairness dictates that subjects be
selected equitably, in other words, giving everyone an
opportunity, and not concentrating on individuals with or
without certain diseases, those located in close proximity
to the service institution, or those of a particular gender.
For example, patients with liver dysfunction commonly
are excluded from research protocols, but in fact are
frequently the ones who receive the study drugs. Consider
also, investigations using predominantly individuals of
one race or ethnic minority simply because of their
availability. Should we encourage the investigation of
drug disposition in these patients, especially as they relate
to the problem being studied?
Thus, selection of subjects has the potential to be an
ethical dilemma. The Belmont Commissions interpretation of the requirement of
is seen in the
following statement:
The selection of research subjects needs to be scrutinized
in order to determine whether some classes (e.g., welfare
patients. particular racial and ethnic minorities, or persons
confined to institutions) are being systematically selected
simply because of their easy availability, their compromised position, or their manipulability. rather than for
reasons directly related to the problem being studied.
Finally, whenever research supported by public funds
leads to the development of therapeutic devices and
procedures, justice demands both that these not provide
advantages only to those who can afford them and that
such research should not unduly involve persons from
groups unlikely to be among the beneficiaries of subsequent applications of the research.

If there are known populations of people in whom

drug disposition and effect differ, should we neglect
enrolling them in clinical trials? Certainly it is expedient
to develop protocols that control for factors that may be a
source of variability. However, in doing this, investigators must not systematically neglect important segments
of the population.

Ethical Issues Related to Clinical Pharmacy Research (ACCP)

Research involving healthy volunteers rarely benefits

the subjects directly, yet may be harmful to them. Should
pharmacists then encourage the development and use of
new technologies or methods (e.g., noninvasive) to reduce
risks while maintaining the scientific integrity of projects? A simple venipuncture exposes both the subject
and the investigator to a degree of risk above that which
occurs in daily life.[6-91If the study drug possesses a saliva : plasma concentration of approximately 1, are we
justified in obtaining plasma samples? If the study intent
is to screen for substances present, investigators should
use noninvasive methods when possible rather than those
requiring venipuncture.

Conflicts of Interest
Conflicts of interest issues are morally relevant because
they represent temptations to do wrong. Million-dollar
budgets have ways of creating ethical dilemmas for
investigators. A prevalent problem is the influence of
commercial interests on independent drug research. Medicine has emphasized disclosure to minimize this problem, but disclosure does not guarantee elimination of
ethical dilemmas.
The American College of Clinical Pharmacy offers
recommendations to minimize conflicts of interest in the
accompanying position statement Pharmacists and the
pharmaceutical industry: guidelines for ethical interactions. The statement addresses questions such as, when
is it permissible to accept an honorarium from a sponsor
for providing a research talk, contributing to a symposium, or arranging a research-oriented training session?
It also discusses the type of research that is appropriate to
be funded. For example, it is unethical to perform a phase
IV study for the sole purpose of familiarizing practitioners with a drug so that they will prescribe or recommend it frequently in the future. Ultimately, the
pharmacist has the responsibility to maintain objectivity
through the unprejudiced and unbiased performance of
research activities regardless of the potential for personal
financial gain.
Another example of a potential conflict of interest is
the use of finders fees to help to identify research
subjects. A finders fee is a fee paid to individuals,
usually nurses, physicians, and pharmacists, who assist
in locating potential research subjects. It may not be
wrong to offer such a fee, but it is probably wrong for
investigators to demand it. It would be unethical to deny
a patient the opportunity to benefit from a study simply
because the investigator would not receive the money. In
lieu of paying finders fees directly, some institutions

339

Ethical Issues Related to Clinical Pharmacy Research (ACCP)

provide credit to a bookstore account or payment to a

special account whose funds can be used only for
educational purposes.

individual Versus Social interest

When is it permissible to deny some benefits, or put some
subjects at risk, for the sake of research and the benefits it
promises? For example, when is it permissible to perform
cost-containment research, and what type of peer review
and informed consent is necessary?["] This is particularly
relevant for pharmacists because many are involved in
this type of data collection and analysis. It is possible that
some subjects may receive a lower standard of care than
that to which they are accustomed. Thus, experimental
strategies that reduce services may expose subjects to the
possibility of harm without benefit.
Political or public policy agendas may exist that do not
necessarily reflect the best interests of research subjects. If
so, pharmacists must maintain the highest standards of
integrity. This may require them to become more involved
in establishing research priorities at federal, state, and
local levels. We should address under what circumstances
it is appropriate to encourage studies that are risky,
potentially unfundable, or would require extensive time or
commitment (which usually means a long delay before
publishable results are generated). The probability of
funding should not determine the direction of research.
Under what conditions is it permissible to delay the
publication of promising results until more substantial
evidence is available? The reverse question is an ethical
dilemma as well. That is, under what conditions is it
permissible to publish promising results even though,
according to accepted standards, more evidence is needed
to validate the results? The increasing newsworthiness of
medical research has given this issue much attention, and
conflicts directly with the established, albeit time-consuming, publication process: manuscript preparation, peer
review, and revision.
Some have criticized the Ingelfinger rule.L111Over a
decade ago, the editor of the New England Journal of
Medicine, Franz Ingelfinger, ruled that no medical
research would be published if it had been published
previously, whether in the scientific or lay press. (The
rule permits previous publication of abstracts or presentations at meetings.) Most major scientific journals have
similar policies.
Vocal patient groups, the lay press, and the public
want medical news as fast as possible; results of new
research are seen or heard daily in the news. The National Institutes of Health has begun releasing some

research results (e.g.. Clinical Alert) directly to health

care providers and the public before the results are published. They deem the results too urgent for the public's
health to be delayed by the publication process." 'I What
are the ethical issues of such early release of research
results, and who is the appropriate authority to decide
what is urgent? How complete should the prepublication
release of medical research be? What is the track record
of prepublication releases? Is it unethical that some
journals take months to print research results because of
their peer review process? Policies should be developed
that define appropriate mechanisms for early release of
research findings, and their effectiveness and impact
should be evaluated.

CLINICAL TRIAL DESIGN

The design of randomized clinical trials introduces ethical
issues."21 Usually, study designs prevent the treatment
from being modified because of the need to collect sufficient data to allow valid statistical inference. Ethically,
clinicians are required to provide their patients with the
best available treatment; however, the justification for a
randomized clinical trial is simply that the best treatment
is not yet known.
What is the proper role for placebo controls? It has
been suggested that, "apart from needing to be both valid
and valuable,' '[131 they must satisfy two premises: there
exists (or there is the likelihood to exist) a controversy
among expert clinicians concerning the relative therapeutic merits of each treatment, including the placebo;
and the design of the study must warrant confidence that
the results will show which of the regimens is superior
and therefore will influence clinical p r a ~ t i c e . " ~ ]
Placebo controls can be justified if the trial is
conducted in an area that falls within one of four
broad categories:

1. Conditions for which no standard therapy exists

at all.
2. Conditions for which standard therapy has been
shown to be no better than placebo.
3. Conditions for which standard therapy has been
called into question by new evidence, creating
doubt concerning its presumed net therapeutic
advantage.
4. Conditions for which validated optimum treatment
is not made freely available to patients because of
cost constraints or other considerations (e.g.,
physical location of treatment centers).

340

These categories should be used as initial guidelines.

The federal Food and Drug Administration desires that
studies of a new chemical entity be compared with
placebo in small groups of patients during phase
I1 testing.
At what point should a clinical trial be stopped
prematurely because enough evidence has been gathered
to show that some treatment is efficacious? Investigators, with the help of statisticians, should develop guidelines that answer this question before the protocol is
submitted to the IRB (or at least prior to data collection). These guidelines should be communicated to all
persons involved in the research effort directly (investigators and research subjects). A safety committee should
be responsible for monitoring data collected during a
trial and stopping the trial if a predefined boundary is
crossed, whether for early evidence of benefit or unacceptable toxicity.

Investigator independence is another important issue.

Almost all industry-funded research is reviewed by the
sponsor prior to publication, and if the results are not
favorable, pressure not to publish may be considerable.
Some protocols forbid the investigator to publish results
without permission; they cite the availability of confidential commercial information as the reason. The implied
threat is that if the results are published, the investigator
will not receive funding in the future. Pharmacists should
be independent investigators with the right and authority
to publish research findings. The intellectual property is
owned by the investigators and their institution, not the
funding agency.

Integrity is a complex concept with associations to conventional standards of morality and personal beliefs about
truth telling, honesty, and fairness. Unintentional investigator bias is a scientific error. Intentional investigator
bias is a form of fraud. Fraud is the deliberate reporting of
what one believes to be false with the intention of deceiving others."41 Within a research program or institution, mechanisms should exist that check for data
trimming, selective reporting, quality control, and originality. Sloppy research is unethical; examples are inconsistencies in record keeping involving research subject
files, sample preparation and other analytical procedures,

Ethical Issues Related to Clinical Pharmacy Research (ACCP)

raw data files, and statistical analysis files. Plagiarism is

another serious offense that compromises scientific integrity and is not acceptable.
Negative data should be published if they are
scientifically sound, particularly when they fill gaps in
current knowledge. They also may decrease redundancy
in future investigations. Investigators should publish
complete information when possible; fragmenting data
sets is discouraged.

CONCLUSI
The research process introduces many ethical questions
particularly relevant to clinical pharmacy investigators.
Most important, investigators must be aware of their
moral responsibility to safeguard the health and welfare of
individuals who participate in research. The informed
consent process is used to ensure that study subjects
understand the conditions of their participation, the
purpose of the study, and the possible hazards involved;
and to ensure that consent is given freely. Investigators
and IRBs must be certain that payments to study volunteers are not excessive or coercive. Finally, clinical
pharmacist investigators must avoid or minimize potential
conflicts of interest by establishing themselves as
independent investigators performing studies with utmost
scientific integrity.

The subcommittee appreciates the helpful comments and

critical review of the following people: David Brushwood, J.D., Peter Iafrate, Pharm.D., Bruce Russell, Ph.D.,
Craig Svennson, Pharm.D., Ph.D., and Russel Thomas,
Pharm.D.
This document was written by the following subcommittee of the 1991-1992 ACCP Research Affairs Committee: David R. Rutledge, Pharm.D., Chair; Clinton
Stewart, Pharm.D., Vice Chair; and Daniel Wermeling,
Pharm.D. Other members of the committee were Kathryn Blake, Pharm.D.; Jacquelien Danyluk, Pharm.D.;
Jimmi Hatton, Pharm.D.; Dennis Helling, Pharm.D.,
FCCP; K. Dale Hooker, Pharm.D.; David Knoppert,
M S c . Pharm.; Patrick McCollam, Pharm.D.; Christopher
Paap, Pharm.D.; Michael J. Rybak, Pharm.D., FCCP;
Kathleen Stringer, Pharm.D.; and Joseph DiPiro,
Pharm.D., FCCP, Board Liaison. Staff editor: Toni
Sumpter, Pharm.D. Approved by the Board of Regents
on May 21, 1993.

Ethical Issues Related to Clinical Pharmacy Research (ACCP)

341

From Pharmacotherapy 1993, 13(5):523-530, with

permission of the American College of Clinical Pharmacy.

1. The voluntary consent of the human subject is

absolutely essential.
2. The experiment should be such as to yield fruitful
results for the good of society, unprocurable by
other methods or means of study, and not random
and unnecessary in nature.
3. The experiment should be designed and based
on the results of animal experimentation and a
knowledge of the natural history of the disease
or other problem under study that the anticipated results will justify the performance of
the experiment.
4. The experiment should be so conducted as to
avoid all unnecessary physical and mental suffering and injury.
5. No experiment should be conducted where there
is a priori reason to believe that death or disabling injury will occur except, perhaps, in those
experiments where the experimental physicians
also serve as subjects.
6 . The degree of risk to be taken should never
exceed that determined by the humanitarian
importance of the problem to be solved by
the experiment.
7 . Proper preparations should be made and adequate
facilities provided to protect the experimental
subject against even remote possibilities of injury, disability, or death.
8. The experiment should be conducted only by
scientifically qualified persons. The highest
degree of skill and care should be required
through all stages of the experiment of those who
conduct or engage in the experiment.
9. During the course of the experiment the human
subject should be at liberty to bring the experiment to an end if he has reached the physical
or mental state where continuation of the experiment seems to him to be impossible.
10. During the course of the experiment the scientist
in charge must be prepared to terminate the experiment at any stage, if he has probable cause
to believe, in the exercise of the good faith,
superior skill, and careful judgment required
of him that a continuation of the experiment is
likely to result in injury, disability, or death to
the experimental subject.

1. Biomedical research involving human subjects

must conform to generally accepted scientific
principles and should be based on adequately
performed laboratory and animal experimentation and on a thorough knowledge of the scientific literature.
2. The design and performance of each experimental procedure involving human subjects
should be clearly formulated in an experimental
protocol which would be transmitted to a specially appointed independent committee for consideration, comment, and guidance.
3. Biomedical research involving human subjects
should be conducted only by scientifically qualified persons and under the supervision of a clinically competent medical person. The responsibility for the human subject must always rest
with a medically qualified person and never rest
on the subject of the research, even though the
subject has given his or her consent.
4. Biomedical research involving human subjects
cannot be legitimately carried out unless the importance of the objective is in proportion to the
inherent risk to the subject.
5. Every biomedical research project involving
human subjects should be preceded by careful
assessment of predictable risks in comparison
with foreseeable benefits to the subject or to
others. Concern for the interest of the subject
must always prevail over the interest of science
and society.
The
right of the research subject to safeguard his
6.
or her integrity must always be respected. Every
precaution should be taken to respect the privacy
of the subject and to minimize the impact of the
study on the subjects physical and mental integrity and on the personality of the subject.
7 . Doctors should abstain from engaging in research
projects involving human subjects unless they are
satisfied that the hazards involved are believed to
be predictable. Doctors should cease any investigation if the hazards are found to outweigh the
potential benefits.
8. In publication of the results of his or her research, the doctor is obliged to preserve the accuracy of the results. Reports of experimentation

Ethical Issues Related to Clinical Pharmacy Research (ACCP)

342

9.

10.

11.

12.

not in accordance with the principles laid down

in the Declaration should not be accepted for
publication.
In any research on human beings, each potential
subject must be adequately informed of the
aims, methods, anticipated benefits, and potential hazards of the study and the discomfort it
may entail. He or she should be informed that he
or she is at liberty to abstain from participation
in the study and that he or she is free to
withdraw his or her consent to participation at
any time. The doctor should then obtain the
subjects freely given informed consent, preferably in writing.
When obtaining informed consent for the research project the doctor should be particularly
cautious if the subject is in a dependent relationship to him or her or may consent under
duress. In that case the informed consent should
be obtained by a doctor who is not engaged in the
investigation and who is completely independent
of this official relationship.
In case of legal incompetence, informed consent
should be obtained from the legal guardian in
accordance with national legislation. Where physical or mental incapacity makes it impossible to
obtain informed consent, or when the subject is a
minor, permission from the responsible relative
replaces that of the subject in accordance with
national legislation.
The research protocol should always contain
a statement of the ethical considerations involved and should indicate that the principles
enunciated in the present Declaration are complied with.

sured of the best proven diagnostic and therapeutic method.

4. The refusal of the patient to participate in a study
must never interfere with the doctor-patient
relationship.
5. If the doctor considers it essential not to obtain
informed consent, the specific reasons for this
proposal should be stated in the experimental
protocol for transmission to the independent
committee.
6. The doctor can combine medical research with
professional care, the objective being the acquisition of new medical knowledge, only to the
extent that medical research is justified by its
potential diagnostic or therapeutic value for the
patient.

Nontherapeutic Biomedical Research

Involving Human Subjects (Nonclinical
iomedical Research)
1. In the purely scientific application of medical
research carried out on a human being, it is the
duty of the doctor to remain the protector of the
life and health of that person on whom biomedical
research is being carried out.
2. The subjects should be volunteers-either healthy
persons or patients for whom the experimental
design is not related to the patients illness.
3. The investigator or the investigating team should
discontinue the research if in his or her or their
judgment it may, if continued, be harmful to
the individual.
4. In research on man, the interest of science and
society should never take precedence over considerations related to the well-being of the subject.

Medical Research Combined with

Professional Care (Clinical Research)
1. In the treatment of the sick person, the doctor must
be free to use a new diagnostic and therapeutic
measure, if in his or her judgment it offers hope
of saving life, reestablishing health, or alleviating suffering.
2. The potential benefits, hazards, and discomforts
of a new method should be weighed against the
advantages of the best current diagnostic and therapeutic methods.
3. In any medical study, every patient-including
those of a control group, if any-should be as-

REFERENCES
1. American Pharmaceutical Association. Code of Ethics;
Washington, DC, 1981.
2. Cloyd, J.C.; Oeser. D.E. Clinical pharmacists in drug
research and development: A historical perspective. Drug
Intell. Clin. Pharm. 1987, 21, 93-97.
3. Anonymous. Trials of War Criminals Before the Nuremberg Militap Tribunals Under Control Council Law No.
10, Vol. 2 ; US Government Printing Office: Washington,
DC, 1949; 181-182.
4. Anonymous. The Nuremberg Code, Appendix 3. In Ethics

343

Ethical Issues Related to Clinical Pharmacy Research (ACCP)

and Regulation (?f Clinical Research, 2nd Ed.; Levine,

R.J., Ed.; Urban & Schwar~enberg: Baltimore, 1986;
425426.
Anonymous. World Medical Association Declaration of
Helsinki: Recommendations Guiding Medical Doctors in
Biomedical Research Involving Human Subjects, Appendix 4. In Ethics and Regulation of Clinical Research, 2nd
Ed.; Levine, R.J., Ed.; Urban & Schwarzenberg: Baltimore,
1986; 427-429.
Department of Health and Human Services. Code of
FedcJral Regulations, 4.5 C.F.R. 46. Pmtec,tion of Human
Subjects; Washington, DC, 1978.
National Commission for the Protection of Human
Subjects of' Biomedical and Behavioral Research. The
Belinont Report: Ethical Principles and Guidelines f o r the
Protpction of Human Subjects of Research. DHEW
Publication 05-78-0012; US Government Printing Office:
Washington, DC; 1978.
Levine, K.J. Basic Concepts and Definitions. In Ethics
and Regulation of Clinical Research, 2nd Ed.; Levinc,

9.

10.

R.J., Ed.; Urban & Schwarzenberg: Baltimore, 1986;

1-18.
Svensson, C.K. Ethical considerations in the conduct of
clinical pharmacokinetic studies. Clin. Pharmacokinet.
1987, 4,217-222.
Brett, A,; Grodin, M. Ethical aspects of human experimentation in health services research. JAMA 1991, 26.5,
1854 1857.
Fletcher, S.W.; Fletcher, R.H. Early release of rescarch
results. Ann. Intern. Med. 1991, 114, 698-~700.
Hellman, S.; Hellman, D.S. Sounding board: Of mice but
not men. Problems of the randomized clinical trial. N.
Engl. J. Med. 1991, 324, 1585- 1589.
Freddman, B. Placebo-controlled trials and the logic of
clinical purpose. IRB: A Review of Human Subjects Research 1985, 7 (2), 1-4.
Levine, R.J. Ethical Norms and Procedures. In Ethics
and Regulation of Clinical Research, 2nd Ed.; Levine,
R.J., Ed.; Urban & Schwarzenberg: Baltimore, 1986;
19-35.
~

11.
12.

13.

14.

PROFESSI 0 NAL 0R G A N IZAT I 0 NS

Annemieke Floor-Schreudering
Europrnn Sooety of Clinical Pharmacy,
Leidcv, The Netherlands

Yechiel Hekster
University Medical Centre, Nijmegen, The Netherlands

oal
In the 20th century, a conviction developed within the
pharmacy profession that the professional knowledge of
pharmacists was not used to its full potential. Activities to
assure the safe and appropriate use of drugs became a new
target, leading to activities in the direction of more paticnt-rclatcd aspects of drug therapy. This perception was
present at about the same time on both sides of thc
Atlantic. It was logically named Clinical Pharmacy,
mcaning a pharmacy activity directed to and in contact
with the patient. The leaders of this new approach wanted
to reinforce their message by founding profcssional organizations preoccupied with the teaching and practical
development of Clinical Pharmacy. In 1979, the birth of
the Amcrican College of Clinical Pharmacy (ACCP) and
the European Society of Clinical Pharmacy (ESCP) took
place simu~taneous~y.

The European Society of Clinical Pharmacy (ESCP) is an

international society founded by clinical practitioners,
rcscarchers, and educators from various countries in
Europe, which constantly looks for new areas of professional practice. Since the formation of the Socicty,
there has been a gradual and sustained growth of clinical
pharmacy in many European countries.

verall
The overall aim of the Society is to develop and promote
thc rational and appropriate use of nicdicines (medicinal
products and devices) by the individual and by society.

344

The goal of ESCP i \ to encourage the development and

education of clinical pharmacist\ in Europe.
The Society tries to achieve this goal by:
1.

Membership activities:
a
Providing a forum for the communication of
new knowledge and developments in clinical
p harmac y .
Dcvcloping links with national and international organizations of pharmacists, teachers,
and students interested in the development of
clinical pharmacy.
0

2.

External relations:
Promoting the value of clinical pharmacy
services among other health care profcssionals, among scicntific societies that share the
same interest, organizations such as WHO
(World Health Organization) and EMEA (European Agency for the Evaluation of Medicinal Products), and generally within the health
service.
0

3. Educational activity:
Enforcing the formation of activities in the field
of clinical pharmacy and pharmacotherapy
through conventions and specific courses.
0
Promoting the inclusion of clinical pharmacy
teaching at pre- and postgraduate levels.

4.

Training:
* Providing accrediting centers, where clinical
pharmacy activities are carried out and which
are prepared to host visiting pharmacists or
pharmacy students in each European country.

Encylopcdia (fClinical Pharmucy

DOI: IO.lOXl/E-ECP
120006205
Copyright 0 2003 by Marcel Dekker, Inc. All rights reserved.

345

European Society of Clinical Pharmacy

5 . Research:
Promoting multicenter research in all areas of
clinical pharmacy.
9
Promoting the participation of pharmacists in
clinical trials and pharmacoeconomic studies.

6 . Publications:
Producing a number of publications on clinical
pharmacy.
Promoting a more widespread use of existing
clinical pharmacy publications.

CLINICAL P H A R ~
Clinical pharmacy is a health specialty, which describes
the activities and services of the clinical pharmacist to
develop and promote the rational and appropriate use of
medicinal products and devices.
Clinical pharmacy includes all the services performed
by pharmacists practicing in hospitals, community pharmacies, nursing homes, home-based care services, clinics,
and any other setting where medicines are prescribed
and used.[21
Activities of the clinical pharmacist are consulting, selecting drugs, providing drug information, formulating and
preparing medicinal products and devices, conducting
drug use studies/pharmacoepidemiology/outcome researcWpharmacovigilance and vigilance in medical devies, studying pharmacokinetics/therapeutic drug monitoring, conducting clinical trials, being aware of the
pharmacoeconomy, dispensing and administrating medicinal products and devices, and providing pre- and postgraduated teaching and training activities to provide training and education programs for pharmacists and other
health care practitioners.[.31

ACTIVITIES OF ESCP

Education and Research

On the day prior to the Annual Symposium, ESCP organizes a one-day full immersion course, Masterclass in
Search of Excellence, on specific topics of interest.
ESCP and EPSA (European Pharmaceutical Students
Organization) jointly organize a Students Symposium,
which aims to bring the clinical pharmacists and pharmacy students together to learn from each others perspectives and experiences.
Different educational and research programs have been
developed and are planned for the coming years (see
ESCP Calendar of Events mentioned below and at www.
escp.nl).
Several collaborative studies, particularly in the field
of drug utilization review and drug evaluation, among
member countries have been or are still in progress.
ESCP offers awards to individual researchers in clinical pharmacy fields in collaboration with sponsors.
A number of accredited centers have been established
to enable European clinical pharmacists to gain experience in a range of clinical pharmacy specialties.
ESCP has produced a database of clinical pharmacy
courses in Europe. Moreover, a long distance Pharmacotherapy Self-Assessment Program (PSAP) published by
ACCP is available at ESCP.

Publications
The editing and issuing of publications and journals is an
important task undertaken by ESCP and comprises the
publication of the Proceedings of the Annual Symposium
in Pharmacy World and Science (PWS). The Society has
adopted a scientific journal Pharmacy World and Science,
where research papers are published and are retrievable.
ESCP Newsletter is a bimonthly publication, serving as
a link between the Society and their members, with news
about the activities of ESCP and of the members.
In addition, ESCP selects existing clinical pharmacy
publications for promotion among ESCP members.

To obtain the goals and objectives, ESCP organizes different types of activities.

elated Organizations
Conferences an
Every year in autumn, the Societys European Symposium on Clinical Pharmacy is held. ESCP also organizes
Spring Conferences, focused on specific themes to provide professional education. During these conferences,
workshops play an important role.

To promote the value of clinical pharmacy services

among other health care professionals and scientific societies, ESCP has established a relationship with societies
that share the same interests: American College of Clinical Pharmacy (ACCP), American Society for Health
Care Systems (ASHP), European Association of Hospital
Pharmacists (EAHP), European Pharmaceutical Students

European Society of Clinical Pharmacy

346

Association (EPSA), Royal Dutch Association for the

Advancement of Pharmacy (KNMP), and the United
Kingdom Clinical Pharmacy Association (UKCPA).
ESCP has been recognized by the Efficacy Working
Party of the European Agency for the Evaluation of Medicinal Products (EMEA) as contributor in the consulting
process. Within the European Forum of Pharmaceutical
Associations and the World Health Organization Regional
Office for Europe (EuroPharm Forum), ESCP is recognized as an observer organization.

The Society is conducted by a General Committee consisting of 12 members. They represent individual countries or, where appropriate, groups of countries. General
Committee members are elected by the membership. The
General Committee meets twice a year, before the Annual Symposium and Spring Conference. (See Table 1
for more information about the General Committee.)

xecutive Committee

The European Society of Clinical Pharmacy International

Office is located at Theda Mansholtstraat 5b, 2331 JE
Leiden, The Netherlands (Phone: + 31 (0)71 5722430;
Fax: + 3 1 (0)71 572243 1; E-mail: [email protected]; Internet: www.escp.nl).

The General Committee elects the Executive Committee,

which implements the resolutions passed by the General
Committee and by the General Assembly. The Executive
Committee, composed of the President, Past-President,
Vice-president, Treasurer, and Chair of the Research and
Education Committee is responsible for the day-to-day
coordination of ESCP activities.

Table 1 General committee members 2001 -2002

~~

Professor M.Alos AlmiAana

Hospital General Castellon, Avda. Benicassim sln, 12004 Castellon, Spain

Ms. C.M. Clark

Brandlesholme, 9 Salthouse Close, BL8 1HD Bury, United Kingdom

Ms.F. Falcao
Hospital de Sao Francisco Xavier, Sevicos Farmaceuticos, Estrada do Forte do Alto Duque, 1495 Lisbon, Portugal
Dr. J. Grassin
Trousseau Hospital, Pharmacy Logipole, Route de Loches, 37 170 Chambray les Tours. France

Dr. E. Grimm Battig

Sonnhaldenweg 28, 4450 Sissach, Switzerland
Professor Dr. Y.A. Hekster
University Medical Centre, Clinical Pharmacy Department, KF 533; P.O. Box 9101. 6500 HB Nujmegen, The Netherlands

Mr. Y. Huon
University Hospital Sart Tilman, Pharmacy Department B 35, 4000 Liege, Belgium

Ms. H. Kreckel
University Hospital Justus-Liebig, Pharmacy Department, Schubertstrasse 89-99, 35392 Giessen, Germany
Mr. K. Linnet
Reykjavik Hospital, Pharmacy Department, Fossvogi, 108 Reykjavik, Iceland

Ms. H. Stenberg-Nilson
Rikshospitalet, Pharmacy, Relis Sor. Holbergs Terrasse, 0027 Oslo, Norway
Dr. F. Venturini
Pharmacy Interna, Policlinico GB Rossi, Piazzale L.A. Scuro, 10, 37134 Verona, Italy

Dr. J. Vlcek
Charles University, Faculty of Pharmacy, Heyrovskeho 1203, 50005 Hradec Kralove, Czech Republic

European Society of Clinical Pharmacy

347

ers

an
The Research and Education Committee is in charge of
the coordination of educational activities, stimulates and
initiates research project, and takes care of the scientific
level of these activities.

The Special Interest Groups (SIGs) of ESCP are intended

to help ESCP meet the evolving needs of its members and
fulfill a growing need for providing targeted services to
ESCP members with similar interests.
The goal is to provide a focal point to gather ESCP
members with common interests and needs in practice,
research, and education, to create a network for:
e
0

e
B

Professional interaction.
Problem solving and discussion of professional issue\.
Continuing education.
Research.
Publications.

The following SIGs are currently active: Cancer Care,

Drug Information, Education and Training, Geriatrics,
Infectious Diseases, Integrated Primary Care, Nutritional
Support, Pediatrics, Pharmacoeconomicr, Pharmacoepidemiology, and Pharmacokinetics.

The Society has an International Office which coordinates

the total operations of the Society, administers the activities of the Society, and implements new policies and
strategies. The staff of the International Office consists of
a director, who i s a pharmacist, and two secretaries. The
director of the ESCP International Office is Annemieke
Floor-Schreudering.

ESCP ha, about 850 members from 48 countries.

Member\ practice in hospitals. clinics, universities, community pharmacies, governmental settings, drug information centers, pharmaceutical industry, and any other
places where clinical pharmacists are employed. The Society has four different classes of members: ordinary
members are individuals who are actively involved in
pursuing the objectives of the Society; honorary members
are those who have distinguished themselves in a particularly honorable way toward the Society; patrons and
sponsors are individuals or corporate bodies, who have
expressed their willingness to support the Society financially; and .student members are individual students or
educational institutions.
During its Annual Symposium, ESCP holds a General
Assembly for all members and patrons of the Society.

C
October 2002

Florencc.

May 2003

Italy
Portugal

3 I st European Symposium
on Clinical Pharmacy
4th Spring Conference o n

C1inic;tl Pharmacy

1. Zelger, G.L.; Scroccaro, G.; Hekster, Y.A.; Floor-Schreudering, A. Introduction to the proceedings. Pharmaceutical
care, hospital pharmacy, clinical pharmacy-what
is the
difference? Pharm. World Sci. 1999, 2f ( 3 ) , lh, A2-A3.
2. Scroccaro, 6.;A16s AlmiRana, M.; Floor-Schreudering, A,;
Hekster, Y.A.; Huon, Y. The need for clinical pharmacy.
Pharm. World Sci. 2000, 22 (l), 27-29.
3. ESCP website. www.escp.nl.

PHARMACY PRACTICE

ISSUES

Univer.sity of Aberdeen, Aberdeen, U.K.

INT
In 1992, a group led by Gordon Guyatt at McMaster
University in Canada first articulated the tcrm evidence based medicine. Evidence-based medicine (EBM)
was defined more recently as the integration of best
research evidence with clinical expertise and patient
values. Despite its recent recognition, EBM has
probably always been practiced by health professionals,
but what has changed is that the quality of evidence and
the clinical benefit of applying it, are now looked at
critically and systematically.
Historically, personal experience, the advice of a
professional colleague or data presented in an article in
a health journal might have been considered sufficient
evidence on which to base a clinical decision. Nowadays,
the importance of using best evidence to underpin
practice is recognized, thereby increasing the likelihood
that an effect can be predicted with confidence. The
growth in EBM has been accompanied by a greater
understanding of the different levels of evidence.
The demand for healthcare increases rclentlessly,
therefore, it is essential that decision makers operate at
both patient and population levels within an evidencebased framework. Evidence is needed for diagnostic tools,
management options (including drug treatments), the
introduction of healthcare models, and patients values
regarding their health service. Scarce resources should
not be spent on treatments which provide little benefit or
which may even do harm. The relative effectiveness of
treatments needs to be assessed where there is competition for limited resources. Valid and reliable information
on the clinical and cost-effectiveness of different options
is therefore needed.
Another reason for the need for EBM is the accelerating pace with which new procedures and treatments are
introduced, with the result that knowledge gained during
training quickly becomes redundant. It is essential,
therefore, to have up-to-date information about best
clinical practice.

348

This article describes how to find and understand the

evidence, and how to apply it in the healthcare setting.

VI
The first stage in practicing EBM is to define the precise
question to which an evidence-based answer is required.
A carefully focused question will inform the search for
relevant evidence, and should (hopefully) avoid excessive
retrieval of irrelevant publications and other information
sources. For example, a clinician who wishes to know
whether it is best to use oral or topical antifungals for the
treatment of vaginal candidiasis could articulate the
question as What is the relative effectiveness of oral
versus intra-vaginal antifungals for the treatment of uncomplicated vulvovaginal candidiasis?
There is a hierarchy] of trial evidence:
la

Evidence obtained from meta-analysis of randomized controlled trials.

Ib

Evidence obtained from at least one randomized

controI1 ed tri a1.

IIa

Evidence obtained from at least one wcll-designed controlled study without randomization.

IIb

Evidencc obtained from at least one other type of

well-designed quasi-experimental study.

111

Evidence obtained from well-designed nonexperimental descriptive studies, such as comparative

studies, correlation studies, and case studies.

IV

Evidence obtained from cxpert committee reports

or opinions and/or clinical experiences of respected authorities.

The above ranking depend$ not only on the type, but

also the quality of the studies. Therefore, a badly conducted randomized controlled trial could be lesq robust
than a well-conducted controlled clinical trial.

Bncjcloyiedia o j Clinical Pharmacy

DOI: 1 0 . 1 OXl/E-ECP 120006244
Copyright C) 2003 by Marccl Dckker, Inc. All rights rescrved.

Evidence Based Practice

349

Table 1 Quality questions for assessing RCTs

0
0
0

*
0
0

avoidance of bias are discussed elsewhere. It is important

to attempt to minimize the effects of bias when reviewing
evidence. It is also useful to contact experts on the subject
of interest, as they will be able to advise on sources of
relevant data and contact details of researchers conducting
trials in the area. Other useful methods of identifying
potentially relevant information include placing notices
about the literature review in professional journals and on
web site noticeboards and searching conference abstracts
and lists of grant awards.
Once the literature search is complete, the identified
trials need to be retrieved and reviewed critically to
decide whether they satisfy specific standards for
inclusion in the review. A list of some important quality
criteria for randomized controls is shown in Table 1. It is
essential that studies that do not meet the necessary
quality standards be excluded from the final analysis.

Were subjects randomly assigned to treatment?

Was randomization done blindly?
Were all subjects analyzed?
Was analysis according to unit of randomization?
Were researchers blind to group allocation?
Apart from the intervention, were the two groups treated
equally?
Were the groups similar at baseline?

It is important to ensure that all the relevant information is identified and critically appraised. This is easier
said than done! Evidence that is unpublished or that is not
in the public domain is difficult to identify and retrieve.
Pharmaceutical companies might not publish unfavorable
results of drug trials, therefore, the clinician or reviewer is
reliant upon the cooperation of the company to provide all
relevant trial data for its specific drug. Trials reported in
the English languager4]and those with positive outcomes
are more likely to be published. Problems can also arise if
trial results have been accepted by a medical journal that
has a long time lag before publication. It may be months
or years before the results are published. The sources and

UNDERSTANDING THE EVIDENCE

The results of trials can be used for different purposes.
They could be combined and reviewed descriptively, or, if

m
T

Table 2 Relative risk

Outcome

Drug A
Drug B

c-d

Where,
a = the number of subjects receiT ing Drug A mith the outcome

b =the number of subjects receiving Drug A without the outcome

c =the number of subjects receiving Drug B Nith the outcome
d = the number of subjects receiving Drug B Mithout the outcome

If the outcome was cure then the relative risk of cure would be calculated as follows:
The risk of cure with Drug A = a ia

b;

divided by the risk of cure with Drug B

c ic + d

with Drug

c ic + d.
Outcome
Yes

No

Total

Durg A

10

20

30

Durg B

50

55

Relative risk = (a / a + b) + (c / c

+ d) = (10 / 30) + ( 5 / 55) = 3.7

This means that cure is 3.7 times more likely with Drug A than Drug B.

350

Table 3 Number needed to treat

Absolute risk iduction(ARR) = (a/(a + b)) - (c/(c + d))
For the above example, using the hypothetical values in Table 2,
ARR=(10/(10+20)) - (5/(5+50))=0.24
Therefore, the NNT = U0.24 = 4
This means that for every four people treated with Drug A, one
additional cure is likely to occur.

the trials are similar enough, their data can be combined

in the form of a meta-analysis. This technique allows
reporting the results to a greater level of statistical confidence because of the increased numbers of subjects included in the analysis.
An alternative statistic which is sometimes quoted is
the odds ratio (OR).This is the odds of an event occurring
in a patient in one treatment group relative to the odds of
the same event occurring in a patient in an alternative
treatment group.
The results of randomized controlled trials comparing
two drugs can be used to generate a statistic called the
relative risk (RR) (Table 2). This is a ratio of the risk of an
outcome with one treatment and the risk of the same
outcome with the other treatment.
While the relative risk is a standard statistic that can
be used to compare treatments, it can be difficult to understand and to relate to practice. For example, although
the relative risk of 3.7 that was calculated above indicates that Drug A is associated with nearly four times
the risk of cure compared with Drug B, this gives no
indication of the practical implications. For this reason,
effects are often quoted as the Number Needed to
Treat (NNT). The NNT is calculated as the reciprocal
of the absolute risk reduction (ARR).In the example in
Table 3, the NNT refers to the number of patients who
need to receive Drug A before an additional cure is
likely to occur.

APPLYING THE EVIDENC

Having identified the evidence from the available information and interpreted it in the context of the original
question, the next step is to apply it to practice. This is a
complex and challenging task. The evidence may suggest benefits from discontinuing existing treatments or
changing to alternative therapy, e.g., using a beta-blocker
in hypertensive patients following a myocardial infarction.] Alternatively, the evidence may recommend
against adopting a new miracle drug such as the anticholinesterase inhibitors for Alzheimers disease.[61

Evidence Based Practice

Currently, much clinical practice is based on established practice and personal experience. Producing
changes in practice will involve the dissemination of information to individual clinicians and persuading them
that, sometimes against their better judgment, there is a
benefit in adopting a new approach. Evans and HainesL7]
cite 12 initiatives to introduce evidence-based practice,
and they are refreshingly honest in identifying the barriers that are encountered. These included the time
required to support change; the resources needed from
existing budgets; a failure to always demonstrate quantifiable gains in the real world; a failure to give ownership
to all parties; and, probably the most difficult and complex of all, changing professional behavior. This last area
is a research topic in its own right and is discussed later
in this article.
Patient resistance to change, as well as professional
resistance, also needs to be addressed. For example, new
evidence may require changes to be made to a patients
current long-term medication. Patients previously satisfied
with their treatment may be reluctant to try a new drug,
despite evidence of greater benefit. A concordant and
patient-centered approach is being promoted.] The clinician has a responsibility to involve their patients in
treatment decisions and to ensure that they understand and
agree with any changes that are made, as well as address
any concerns that they may have. In the interests of maximizing patient outcomes and cost-effective use of medicines, it is paramount that patients understand and agree
with new or existing treatments. Within this framework,
management decisions may not be in line with current best
evidence, giving rise to a debate about the legal implications and professional ethical issues of this scenario.
It is important to remember that EBM applies to a
range of providers at a variety of levels. Thus, it should be
used to support decision making by all healthcare
providers, not just medical clinicians. It is for this reason
that the term Evidence-Based Practice (EBP) is increasingly used. Pharmacy, nursing, physiotherapy, and all
other professions allied to medicine should, where
possible, be providing evidence-based treatment at an
individual and service level. For example, evidence can
support decisions about whether to treat stroke patients
in a dedicated stroke unit or as part of a general ward.[]

CRITICISMS OF EVIDENCE- BASE^ MEDICINE

There are two levels of criticism applied to evidencebased medicine. The first relates to the widespread
dependence on the randomized controlled trial, and the
second relates to the patient-population dichotomy.

Evidence Based Practice

Concern has been expressed that gold standard

evidence, i.e., the RCT, may not be as robust as it first
appears. Critics of this study design argue that the
patient populations are highly selected. Randomized
controlled trials often exclude patients above a certain
age or those who are taking other concomitant medications or who have significant comorbidities. Additionally, participants in RCTs often have intensive support
from medical, nursing, and research staff, contrary to the
normal situation. The reasons for these exclusions and
enhanced care are self-evident, but they may mean that
the results are not generalizable to the wider patient
population. A comparison of randomized and nonrandomized studies has also identified that subjects excluded
from RCTs tend to have worse prognosis than those who
are included.] Furthermore, subjects entered into RCTs
for evaluation of treatment for existing conditions may
be less affluent, less educated, and less healthy then
those who are not. The opposite is true for trials of preventive interventions.[ I
Secondly, clinicians have argued that evidence-based
guidelines do not accommodate individual patients and
their specific circumstances or needs. It may be necessary
to remind clinicians that guidelines are not tramlinesthey apply to a specific population, and their recommendations should be tailored to the needs of their individual
patients. This is discussed later in this article.

PATIENT LEVELS
With increasing healthcare costs, particularly in the field
of drug treatments, decisions regarding the uptake of new
drugs may be made at organizational rather than individual clinician or patient level. In the United Kingdom,
this is particularly true in areas where NHS budgets constrain both the choice of treatment and patient selection.
EBM can be used to inform these policy decisions, as it
can assess both the cost-effectiveness and clinical effectiveness of treatments. The final decision can take into
account the wider ramifications of alternative treatments,
such as the possible need for residential or surgical care or
the impact on lay carers. A decision may be made at a
population level that a new drug should not be introduced
because of the adverse overall health economic balance,
whereas at an individual level, it could be worth trying.
An example of this patient versus the population dilemma is illustrated by the use of the expensive interferon-beta-lb to treat secondary progressive multiple

351

sclerosis (MS). The evidence tells us that treatment with

interferon-beta-1b will delay time to wheelchair dependence and prevent relapses in some subjects. However, the
NNT is 18 and at a population level, the economics mitigate against making this a recommended treatment. ]
Conversely, despite their cost, there has been considerable
use of statins as lipid-lowering agents to reduce cholesterol levels in targeted patients. This is because the
evidence shows long-term reduction in further coronary
events, and the exact health gain can be calculated and is
deemed w o r t h ~ h i l e . ~This

intervention is both clinically and cost effective.

Ultimately, it is the clinician who has to weigh the
costs and benefits for each individual patient, taking into
account the evidence but also considering patient factors.
This has been summarized as conscientious, explicit and
judicious use of current best evidence in making decisions
about the care of individual patients.41

WHAT TO DO WHEN THERE IS NO

EVIDENCE OR EVIDENCE IS INCOMPLETE
The EBM movement is a relatively recent endeavor.
With such a wide range of treatments available and
numerous conditions, it is inevitable that there will not
always be evidence to inform decision making. This may
be due to a lack of collation of the available research
evidence or a lack of research per se. In these instances,
there are several options depending on the immediacy of
the decision.
If a decision needs to made quickly, advice should be
sought from the most experienced practitioner on the
subject. This advice should be interpreted with caution
and considered in light of whatever published literature
exists. This should be judged on the basis of the ranked
levels of evidence included earlier in this article. New
drugs may be tried in the context of local clinical trials.
If this is the case, these trials should be expertly designed
and conducted in collaboration with other colleagues.
This means that while a treatment may not ultimately be
the best, it will have been used in a controlled way such
that it has contributed to generating future evidence.

CLINICAL ~FFECTIVENESSAND
CLINICAL GOVERNANCE
There is a growing emphasis on the accountability of
individual clinicians and organizations that provide

Evidence Based Practice

352

healthcare. EBM contributes to the definition of criteria

used for clinical performance indicators. This forms the
basis of assessing the clinical effectiveness of services.
Increasingly, clinicians and their corporate managers are
held responsible for the delivery of quality care; this is
known as clinical governance. Despite the caveats for
EBM summarized above, the knowledge and understanding it has promoted now underpin the healthcare infrastructures that exist today.

MACISTS ROLE
Pharmacists can contribute to the delivery of evidencebased care.] At a population level, pharmacists clinical
knowledge and analytical strengths can be used to facilitate the production of systematic reviews, the interpretation and analysis of findings, and the development of
guidelines. At a patient level, pharmacists are consulted in
both primary and secondary care, and may be a useful
vehicle for transfer of evidence-based information to the
clinician, being able to give a more objective decision than
the doctor faced with a patient with alternative expectations.61 Pharmacists can influence the choice of prescribed drugs mediated either through the GP to the
patient, or face to face with the patient.17]
In many countries, a wider range of drugs is available
for purchase from pharmacies without the need for a
prescription. This has enabled pharmacists to provide
treatment and advice for a greater range of minor illnesses. Although there have been concerns that pharmacists
and their staff may give inappropriate advice,[l8-*I the
use of evidence-based guidelines to support their treatment of minor illness is currently being explored.[221

RESOURCES FO
EVIDENCEElectronic databases of peer-reviewed healthcare journals
(primary references) include MEDLINE and EMBASE.
The Cochrane Collaboration library contains a database of
systematic reviews as well as a database of RCTs and
controlled clinical trials. Medical librarians will be able
to advise and perhaps provide training on performing
literature searching and retrieval. Hospital-based drug
information centers will likely have access to a range of
electronic databases. The Royal Pharmaceutical Society
of Great Britains information center has a number of
databases that can be searched for information that is of
particular relevance to drug therapy and pharmaceutical
care. It is likely that most national pharmaceutical
organizations have similar resources.
One of the greatest resources for EBM is the World
Wide Web. There are numerous sites that provide
information on EBM. including literature retrieval and
review, EB guidelines, and so on (Table 4).

GETTING EVIDENCE INTO PRACTICE:

DISSEMINATION AND IMPLEMENTATION
The mere dissemination of information (i.e., evidence)
is unlikely to achieve behavioral change.[231In order for
evidence to influence practice, active dissemination and
implementation strategies need to be employed. It is recognized that individual beliefs, attitudes and knowledge
influence professional behavior and that other factors
including organisational, economic and community environments of the practitioner are also important.[241 It
has been suggested that implementation strategies that

Table 4 Suggested EBM-related web sites

Adept Programme
Agency for Healthcare Research and Quality (USA)
Bandolier
Critical Appraisal Skills Programme
National Guideline Clearing (USA)
Netting the Evidence
NHS Centre for Evidence-Based Medicine
National Institute for Clinical Excellence (UK)
Primary Care Clinical Practice Guidelines
Scottish Intercollegiate Guidelines Network (SIGN)
The NHS Centre for Reviews and Dissemination
TRIP Database
UK Cochrane Centre
Virtual library

www.shef.ac.uk/-scharrlirladept
www.ahcpr.gov/
www.jr2.ox.ac.uklbandolier/
www.phru,Org.uk/-casp/index.htm
www.guideline.gov/index.asp
wwwshef.ac.uk/-scharrlirlnettingl
www.minervation.com/cebm/
www,nice,org.uk
www .medicine.ucsf.edu/resources/guidelinesl
www.sign.ac.uk

www.york.ac.uWinst/crd/welcome.htm
www.tripdatabase.com/index.cfm
www .cochrane.org/
www.shef.ac.uk/-scharrlirlcore.htm1

Evidence Based Practice

address barriers to change may be more effective than

those that do not.[241A comprehensive review of implementation strategies is presented in the Effective Health
Cure Bulletin: Getting Evidence Into Practice.[241
The use of guidelines as a method of summarizing
evidence is discussed elsewhere in this encyclopedia.
There has been considerable evaluation of the effectiveness of different guideline implementation strategies as
methods of eliciting behavior change among healthcare
professionals. Most implementation research has targeted physician behavior. However, as greater emphasis is
placed on multidisciplinary healthcare teams, strategies
need to be identified, tested, and adopted, which are effective in promoting evidence-based practice among all
health professional groups.
Mass media is a method commonly used to disseminate information to large audiences. This strategy usually
involves the dissemination of printed materials (e.g.,
guidelines, therapeutic bulletins) to specific health professionals (e.g., physicians, pharmacists). There is little
evidence to support the use of this method, as it is largely
ineffective in influencing behavior change.[251
Educational outreach visits (also known as academic
detailing) have been used by the pharmaceutical industry
for decades to influence the prescribing behavior of
physicians. Although there is little published empirical
evidence of the effect of the pharmaceutical industrys
promotional activities on prescribing patterns, the investment of 57% of their pharmaceutical promotion budget on
pharmaceutical representatives and 11% on promotional
literature, gives some indication of its importance.[261
There is considerable research evidence of the effectiveness of educational outreach as a behavior change strategy
for healthcare professionals.[271 It is no surprise (considering their origin) that educational outreach visits have
been shown to be effective in achieving change in prescribing behavior among physicians.[*]
The use of opinion leaders as an implementation
strategy has been evaluated in a number of studies, the
results of which are inconclusive.[281This method relies
on persuasion (i.e., the persuasive ability of the opinion leader) to influence the behavior of the target
audience. Further evaluation of this strategy is required,
including methods of describing characteristics of opinion leaders and how to identify individuals who satisfy
these criteria.

353

patients receiving the most appropriate treatment. It is

also used to inform policy making about both medical treatments and new services, including models
of healthcare.
While there are still some caveats, some of which have
been highlighted in this article, EBP is the goal to which
all healthcare professionals should aspire.

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~

Evidence-based practice is increasingly recognized as

the best way to maximize the chances of individual

Evidence Based Practice

354

13. Reckless, J. The 4s study and its pharmacoeconomic

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controllcd trial in primary care. Age Ageing 2001. 30,
215 221.
17. Beney, J.; Bero, L.A.; Bond, C. Expanding the Roles of
Outpatient Pharmacists: Effects on Health Services
Utilisation, Costs, and Patient Outcomes (Cochrane
Review). In The Cochmae Library, Ixsue 3; 2002, Oxford:
Update Software.
18. Goodburn, E.; Mattosinho, S.; Mongi, P.; Waterston, A.
Management of childhood diarrhoea by pharmacists and
parents: Is Britain lagging behind the Third World'! Br.
Med. J. 1991, 302, 440-443.
19. Krska, J.; Greenwood, R.: Howitt, E. Audit of advice
providcd in response to symptoms. Pharm. J. 1994, 252,
93-96.
20. Anonymous. Counter advice. Consumers arc still not
receiving the right advice when buying medicines from
pharmacists. Which 1999. 22-25 April.
21. Mobcy, N.; Wood, A.; Edwards, C.; Jepson, M.H. An
-

22.

23.

24.
25.

26.
27.

28.

assessment of the response to symptoms in community

pharmacies. Pharm. J. 1986, 237, 807.
Watson, M.C.; Bond, C.; Grimshaw, J.M.; Mollison, J.;
Ludbrook, A. Educational Strategies to Promote EvidcneeBased Practice: A Cluster Randomised Controlled Trial
(RCT). I n Health Services Research and Pharmacy
Practice Conference Proceedings; 200 I .
Mittman, B.S.; Tonesk, X.; Jacobson, P.D. Making good
the promise: Disseminating and implementing practice
guidelines. Qual. Rev. Bull. 1992, 18, 413 422.
Anonymous. Getting evidence into practice. Eff. Health
Care Bull. 1999, 5 (1).
Freemantle, N.; Wolf, F.; Grimshaw, J.M.; Grilli, R.; Bero,
L. Printed Educational Materials: Effects on Professional
Practice and Health Care Outcomes (Cochrane Review). In
The Cochrane Library, I . s . T L2;
~ ~2001.
Association of the British Pharmaceutical Industry.
PHAKMA Fucts & Figures; ABPI: London. 1997.
Thompson O'Brien, M.: Oxman, A,; Davis, D.; Haynes,
R.; Freemantle, N.; Harvcy, E. Educational Outreach
Visits: Effects on Professional Practice and Health Care
Outcomes (Cochrane Review). In The Cochrune Librury,
Issue 3; 2002, Oxford: Update Software.
Thompson O'Brien. M.A.; Oxman, AD.; Haynes, R.B.;
Davis, D.A.; Freemantle, N.; Harvey, E.L. Local Opinion
Leaders: Effects on Professional Practicc and Health Care
Outcomes (Cochrane Review). In The Cochrune Library,
I S S U P 3; 2002, Oxford: Update Software.

PROFESS I0 NA L DEVE LO P M E NT

c
University o f Georgia College o f Pharmacy,
Athens, Georgia, U.S.A.

The term ,fellowship is used to designate training

programs or to indicate status within a profcssion or
professional organization. In pharmacy, the accepted
definition for a fellowship is a directed, highly individualized, postgraduate program designed to prepare
the participant to become an independent researcher.
This definition was adopted by a coalition of seven national pharmacy organizations to distinguish fellowship
from residency training. This definition is contrasted
with that for a resideency which is an organized, directed, postgraduate training program in a defined area
of pharmacy practice. Training fellowships may occur
at any stage of education and are commonly referred to
as predoctorul (usually at the undergraduate levcl) or
postdoctom1 (postgraduate). This article includes discussion of fellowship as a postdoctoral research training program.

DEFINITIONS
A member of a professional organization may be
designated as a fellow to recognize accomplishrncnts, experience, or some other laudable standing in the profession. For example, a person may be a Fellow of the
Arncrican College of Clinical Pharmacy (ACCP) or the
American Society of Health-System Pharmacists (ASHP).
This dcsignation does not indicate completion of a training program nor proficiency in rcscarch.
Fellowships are offered by many institutions, including colleges and univcrsities, government entities such as
the National Institutes of Health and the Centers for
Disease Control and Prevention, pharmaceutical manufacturers, healthcare systems, and professional organizations. Most pharmacy fellowship training programs
are offered by colleges of pharmacy or academic medical centers.

.%7cyck~~~c~dia
of Clirzic.ul Pharmacy
DOI: I0.1081/E-ECI120006357
Copyright 0 2003 by Marccl Dekker, Inc. All rights reserved.

Generally, fellowships are generally highly individualized programs to develop competency in research,
including conceptualizing a research problem, planning and conducting research processes and experiments, analyzing data, and reporting of results. These
programs are conducted under the close supervision
of an experienced research mentor or preceptor. More
so than most residencies, a fellowship is guided by
one person or a small group of individuals. Fellowships are generally 12 or 24 months in duration and
fellows often complete formal courses in selected topics such as research design, statistics, or research
methods before or during a fellowship. Fellows should
possess basic pharmacy practice skills relevant to the
knowledge area of the fellowship. These skills are
acquired through training in a Pharm.D. program, a
residency, or practice experience. For most individuals, a residency should be completed before bcginning
a fellowship.
The goal of fellowship training is to produce an
individual capable of conducting collaborativc research
or functioning as a principal investigator. A fellowshiptrained individual will usually work for a collcge of
pharmacy, academic medical center, pharmaccutical
company, or contract research organization. Researchintensive positions often indicate a hiring preference for
those with fellowship training.

GUIDELINES FOR CLINICAL FELLOWSHI

TRAINING PROGRAMS
In 1987 a document with specific guidelines for clinical
fcllowship training programs in pharmacy was approved
by ACCP and the American Association of Colleges of
Pharmacy.[21The guidelines, which have been updated by
ACCP, relate to the training program overall, preceptor
qualifications, fellow qualifications, and the fellowship
experience, as follows.

355

356

Fellowships in Pharmacy

1. In general, a commitment of 80% of fellowship

training time to research activities over a period of
at least two years.
2. Administrative institutional support for the preceptors research program and the fellowship
training program.
3. Availability of graduate-level course work in the
area of the fellowship.
4. Availability of personnel to teach laboratory-based
and clinical research skills.
5. Ready access to a medical library and computer
facilities.

Preceptor Qualifications
1. A clinical scientist with an established record of
research accomplishments, which may be exemplified by:
a. Fellowship training or equivalent experience.
b. Principal or primary investigator on research
grants.
c. Published research papers in peer-reviewed
pharmacy/medical literature where the preceptor is primary or senior author.

2 . Active collaborative research relationships with

other scientists.
3. Expertise in pharmacotherapeutics in the area
of specialization.

Fellowship Applicant Requirements

1. Pharm.D. or equivalent experience.
2. Residency or equivalent experience.
3. High level of motivation for a research career,

3. Submission of a protocol to the appropriate institutional review committee.

4. Research experiences including study conduct and
data collection related to the field of specialization.
5 . Experience in statistical analysis of data.
6. Preparation and submission of abstracts and
manuscripts for publication in peer-reviewed
journals.
7 . Formal presentation of research at peer-reviewed
scientific meetings.
8. Participation in journal clubs, research workshops,
and seminar series.
9. Instruction in biomedical science ethics.

REVIEW OF FELLOWSHIPS
In an effort to improve fellowship training, ACCP
instituted a program for peer review of research fellowships training programs to assure quality of these programs. This is a voluntary process conducted by an ACCP
committee to determine whether a program meets the
ACCP Guidelines for Research Fellowship Training
Programs as detailed above. In this process, both the
preceptor and the fellowship site are evaluated. A positive
review indicates that the program meets the guidelines. At
present, 15 fellowship programs have been recognized as
meeting the g ~ i d e l i n e s . ~ ~ ]

FELLOWSHIP RESOURCES
An excellent resource for information about pharmacy
fellowships is the ACCP Directory of Residencies and
Fellowships.[31 This source provides information on over
100 individual fellowship programs. Additional information on fellowships can be obtained from the Academy of
Managed Care P h a r m a ~ y ~and
] the American Pharmaceutical Associati~n.[~Currently, fellowships can be
served in the following areas:

Fellowship Experience
The initiation and completion of a research project,
including:

1. Development of at least one scientific hypothesis

and experimental methods to test hypothesis.
2. Preparation and submission of a grant proposal.

* Ambulatory care.
* Cardiology.
* Clinical pharmacology.
* Critical care.
0
Drug development.
0
Drug information.
0
Family medicine.

351

Fellowships in Pharmacy
a
0

e
0

e
e
m
m
e

m
e
0
0

m
0

Geriatrics.
lnlcctious diseases.
Internal rnedicinc.
Managed care pharmacy.
Nephrol ogy .
Neurology .
Oncology.
Outcomes research.
Pediatrics.
Pharmacoeconomics.
Pharmacoepidcmiology.
Pharmacokinetics.
Psychiatry.
Pulmonary.
Rheumatology .
Translational rcscarch.
Transplantation.

Funding for kllowships varies from year to year and

has been available from pharmacy organizations including ACCP, ASHP, American Society of Consultant
Pharmacists, and the American Foundation for Pharmaceutical Education.

I.

Anon. Definitions of residencies and fellowships. Am. J.

Hosp. Pharm. 1987, 44, I143 1144.

Anon. Guidelines for clinical fellowship training programs.
Pharmacotherapy 1988, 8, 299.
3. 2001 Directory or Residencies und Fellowships; American
College of Clinical Pharmacy: Kansas City, 2001.
4. http://www.arncp.org/public/pubs/j~urnal/v~)lS/currentl
reports.htrn1 (last accessed on June 19, 2001).
5. http://www.aphanet.org/ (last accessed June 19, 2001).
2.

P R O F ESS I 0NA L R ESOURC E S

P

ba
First DataBank, Inc., San Bruno, California, U.S.A.

Successful computerization and drug-related decision

support is achieved to a significant degree within the
profession of pharmacy. Pharmacy has been a leader
among healthcare professions in embracing computerization. Drug databases and knowledge bases arc now thc
backbone of pharmaceutical care or pharmaceutical
decision support.

Our mission is to be the best provider of point-of-care

decision support knowledge bases that provide outstanding value to patients and to our customers. We are committed to exceeding our customers expectations so that
they regard us as the best company in our industry. We
will achieve this position through the comprehensiveness and quality of our data, the responsiveness of our
service, and our understanding of their business problems. While continuing to grow, we will provide an open,
supportive, challenging, and team-oriented environment
within which our staff members can achieve job satisfaction, professional and personal growth, and compensation based on company and individual performance.
We will actively work to increase our impact on the
quality of healthcare.
First DataBank is one of the worlds leading suppliers of healthcare knowledge bases, supplying drug
knowledge bases, as well as medical diagnostic and
nutrition software to system vendors. First DataBank
serves hospitals, hospital pharmacies and laboratories,
retail pharmacies, physician clinics and group practices, insurers, managed care organizations, pharmacy
benefits managers, claims processors, employers, utilization review organizations, government, pharmaceutical manufacturers, wholesalers, and all 50 state Medicaid programs.

358

First DataBanks professional staff is committed to

deliver comprehensive and accurate information to physicians, pharmacists, nurses, dietitians, and other healthcare professionals to be uscful in a variety of healthcare
settings. Drug information to be used directly by consumers (i.e., patients and their families) is also another
focus of our drug knowledge bases. Thcsc knowledge
bases are updated continually and are available to accommodate any update schedule, providing the immediate
access that businesses need to perform mission critical
functions and to realize significant time and financial
savings. Enhancements in the delivery of pharmaceutical
care have increased the nced for First DataBank to deliver
clinically significant drug information in a timcly manner. Therefore, updates to products containing clinical knowledge bases ( i t . . drug-drug interactions or patient education materials) are made available on a
weekly basis. Institutional drug buying practices, retail
pharmacy services, and Pharmacy Benefit Manager functions have created the need for daily updates of drug
pricing information.
First DataBank also has many international drug
databases that were developed by a professional staff
consisting of native language speakers who best understand how drugs are used in other countries. As the Internet and global travel make the world a smaller
place, these knowledge bases will become even more
omnipresent and obligatory.
Experience is critical to develop and maintain a comprehensive database of drug information. First DataBank
has been in this business for over 20 years, having spent
virtually all of that time developing, maintaining, and
enhancing the most comprehensive drug, medical, and
nutrition knowledge bases in the world. Our knowledge
bases have evolved along with new technologies in
healthcare and continue to develop as thc Internet and
mobile devices become part of clinical practice. First
DataBank offers customization for every clients file in
terms of record format, formulary selection, media specifications, updates, and user-specific data elements. As

E~zcyclopediuof Clinical Pharmucy

DOl: 10.1081E-ECP 120006382
Copyright 0 2003 by Marcel Dekker, Inc. All rights reserved.

First DataBank, Inc.

359

a result. our customers save valuable programming and

processing time.

Drug Indications, Pregnancy and Lactation Precautions,

GeriatridPediatric Warnings, Minimumhlaximum Dose
Checking, and Duplicate Therapy/Ingredient Checking. A
few specific modules are highlighted.

First DataBank creates and maintains some of the largest

and most comprehensive drug and healthcare knowledge
bases in the world, including NDDF PlusTM,based on the
industry standard National Drug Data FileE. One of the
industrys most trusted and widely used sources of up-todate drug information, NDDF Plus combines descriptive
and pricing data with a selection of advanced clinical
support modules. NDDF Plus delivers information on
every drug approved by the Food and Drug Administration (FDA). Clinical modules are available to support
healthcare professionals in making critical decisions
about dosing and orders, interactions, allergy alerts, disease contraindications, drug identification, and much
more. Plus, several modules offer drug information specifically written for the consumer. NDDF Plus is used in a
wide variety of applications, such as:

Patient Education Monographs were written for consumers. They are both comprehensive and customizable,
covering the most common prescription and OTC medications. The format of these patient education monographs is flexible and is available in English and Spanish.
Other patient education materials are available including
Prioritized Label Warnings that indicate which ancillary
stickers should be placed on a medication being dispensed and Counseling Messages to be used as reminders
for healthcare professionals.

e
e
b

e
0

e
b

b
b

Determining drug indications.

Identifying potential contraindications.
Helping prevent adverse drug events.
Identifying drug-drug and drug-food interactions.
Identifying potential drug interactions with alternative
therapy agents.
Offering printed patient education and counseling
messages.
Prioritizing medication warning labels for patients.
Listing recommended doses for common drugs.
Performing indication-specific dose range checking.
Identifying undesired effects of drugs on lab tests.
Supporting electronic medical records.
Handling prescriber order entry.
Analyzing drug pricing trends.
Facilitating drug formulary management.
Accelerating claims processing and adjudication.

First DataBank offers comprehensive international drug

knowledge bases for several countries outside the United
States, including Canada, Argentina, and Australia. First
DataBank Europe, located in Exeter, England, develops
drug knowledge base products for the United Kingdom.
Examples of clinical functionality in drug knowledge
bases are described below for Patient Education, Drug
Interactions, and Prescriber Order Entry modules. Many
other pharmaceutical decision support modules are also
available and include Drug/Disease Contraindications,

Drug interactions
First DataBanks drug interaction modules are meant to
be able to detect all clinically significant drug-drug
interactions for a given patient in either a prospective or
retrospective manner. Drug-food interaction information
is also available. Interactions are classified by severity,
and documentation levels are also noted in coded fields
for searching and filtering applications. Full text monographs describe the drug-drug interaction in detail and
include reference citations in MEDLINE format. A
consumerized version of the drug-drug interaction
monograph has been created for systems that allow
patients to monitor their medications.

Prescriber Order Entry

Prescriber Order Entry Module (POEMTM)provides a
database of the most common medication orders. These
orders are specific to drug, route of administration, formulation, age, indicatioduse, and weight or body surface area, if applicable. This enables more accurate
and efficient point-of-care computerized order entry applications to prevent errors at the prescribing stage of
drug delivery.

INTEGRATED CO
Success in todays drug information marketplace requires
products that can be developed quickly and economically,
lowering the cost of entry into a given market. Toward
that end, First DataBank offers a number of application

First DataBank, Inc.

360

development toolkits that minimize lead times and make

more efficient use of scarce resources.

rug l n f o r m a t ~ oFrameworkTM
~
The Drug Information FrameworkTM
enables developers to
build healthcare solutions faster, using the time-tested
NDDF Plus knowledge base and critical decision-support
modules. The Framework gives developers a choice of
technologies and access layers, so it can adapt to most
platforms, operating systems, development tools, and relational databases. Application environments can include
the Internet; client/server networks; stand-alone desktops;
and handheld wireless devices.
Drug Information Framework components encapsulate
drug information in intuitive objects, which shortens the
typical programmer learning curve and development cycle. These components simplify system implementation,
resulting in quicker, easier deployment of systems offering
point-of-care, patient-specific drug information, as well as
convenient access to full-text clinical monographs.

HFS FrameworkTM
The AHFS FrameworkTMenables developers to easily
embed drug content into pharmacy and clinical information systems. It can be used to rapidly integrate two
respected drug knowledge bases: the American Hospital
Formulary Service (AHFS) Drug Information i3 monographs, and First DataBanks NDDF Plus. Combined, they
allow healthcare professionals to have seamless access to
comprehensive drug information, within their usual workflow systems.

With Rx InhandTM,developers have a powerful tool for

creating stand-alone handheld applications. This drug
navigation and drug utilization review (DUR) engine
enables developers to easily create systems for use by
physicians to write prescriptions and to screen them on a
handheld device for possible medication errors, thus
potentially minimizing adverse medical events.

RxWebTMprovides instant access to drug information,

navigation capabilities, and clinical-screening functionality over the Internet. Using the latest Web browser
technology, RxWeb enables the developer to offer proven drug screening (via NDDF Plus) with little or no

development time. With RxWeb, software developers

can create Web-based applications that provide information on over 100.000 marketed drugs, as well as alternative therapies.

First DataBank has developed numerous drug reference

products for healthcare applications, in both print and
electronic forms. Most of these products can be deployed
on an individual desktop, a local area network and, in
some cases. over the Internet or intranet,

AHFSfirstTMcombines into one easy-to-use package two

of the most widely used sources of unbiased drug
information-NDDF Plus and the AHFS Drug InformationE monographs from the American Society of HealthSystem Pharmacists$. It links over 100,000 drugs from
NDDF Plus to the AHFS monographs, providing maximum coverage from two respected sources. This sophisticated reference makes it possible, in just seconds, to find
information on drug interactions, contraindications, adverse reactions, and precautions. The AHFSfirst Web
edition brings this capability to users of the Internet or
intranets. AHFS Drug Information monographs are also
available as a data-only product.

Evaluations of Drug InteractionsTM

First DataBanks Evaluations of Drug InteractionsTM
(EDI) provides the most comprehensive printed source
of drug-drug interaction information available. Containing interactions on both prescription and over-the-counter
drugs, this two-volume loose-leaf textbook of drug monographs is the only source endorsed by the American
Pharmaceutical Association.

In addition to drug information products, First DataBank

has developed several interactive software products intended for direct use by healthcare specialists, including
nutritionists and physicians.

utritionist proTM
Nutritionist ProTMsoftware represents the next generation of nutrition-analysis tools from First DataBank.

First IFataRank, Inc.

With the most comprehensive food knowledge base and

set of program features, Nutritionist Pro provides thorough analysis of diets, recipes, and menus. The intuitive user interface design and powerful functionality of Nutritionist Pro can help ease the workload and
boost the productivity of nutrition professionals in virtually any healthcare delivery, food service, or educational setting.

ANTICIPATING FUTURE NEEDS

In healthcare, we are today at a crossroads of yet, another
of many notable technical developments. Personal
computers have become ubiquitous and easier to use for
healthcare professionals and patients. The newly available
mobile or handheld devices have become more practical
for real-time computing. Through the Internet or handeld device, there is ready access to a patients medical
information. With these tools, the art of practicing medicine is truly about to change. An electronic information resource for thc Internet and for handheld devices,
as for other platforms, requires that the data meet specific standards of reliability. First DataBank information is tried and true, a tested, authoritative source of
such information.
First DataBank has anticipated this wave of technological change in medicine and has developed an array
of software and middleware for ease and effectiveness of decision support implementation for these platforms. Time-to-market has become an absolutely critical
factor in the succcss of healtheare IT applications. The
Internet, cost containment, IT undercapitalization, and
a host of other factors impacting the healthcare indus-

361

try have created a demand for the rapid deployment of

new applications.
First DataBank is not only meeting healthcare challenges but is also leading the industry into an era of
greater patient safety and knowledge.

FIRST DATABANK AS A HEARST

CORPORATION SUBSIDIARY
The visionary behind First DataBank is founder and
President, Joseph L. Hirschmann, Pharm.D. Doctor
Hirschmann started the company after a distinguished
academic career at University of California, San Francisco. Another of his accomplishments that lives on today
is the Textbook of Therapeutics: Disease and Drug Munugement, which was previously known as Clinicul Phurmacy and Therupeutics.
First DataBank became part of the Hearst Corporation
in 1980. The Hearst Corporation is one of the worlds
largest diversified communications companies, with interests in newspapers, magazine, book and business publishing, television and radio broadcasting, cable network
programming, and new media activities. First DataBank
remains under established independent leadership, while
benefiting from the support and financial stability offered
by The Hearst Corporation.

LOCATIONS
The First DataBank home office is located in San Bruno,
California, just a few miles from the San Francisco airport. The company also has offices in St. Louis, Missouri;
Exeter, England; and Indianapolis, Indiana.

Medical College of Georgia Hospitals Kr Clinics, Augusta, Georgia, U.S.A.

I
Formulary systems are an essential tool used in a variety
of settings including hospitals, ambulatory clinics, health
plans, pharmacy benefit management companies, and
govcrnrnent agencies. This tool, if used correctly,
promotes rational, clinically appropriatc, safe, and costeffective pharmaceutical carc.
The term formulary has been used to describe a
published list of medications used by an organization,
from which prcscribers can choose therapy for their
patients. Historically, an open formulary implied that
the list was fairly inclusive of any medications the
prescribers wanted. A closed formulary was a finite
list that reflected the clinical judgment of a group of
physicians, pharmacists, and other health care profcssionals meeting regularly to choose the most appropriate
drugs for the list. Most pharmacists have stopped using
open and closcd because few contemporary
formularics arc truly open. A formulary now typically
refers to a book or on-line publication used by the
organimtion that contains the approved drug list and other
prescribing information dccined useful by its editors.
A forinulary systcm goes much beyond a publication
or list of drugs. A coalition of national organizations
representing hcalth care professionals, government and
business leaders has offered this definition:
Drug Formulary System-an ongoing process whereby ii
health care organization, through its physicians, pharmacists, and othcr hcalth care profcssionals, establishes
policies o n the use of drug products and therapies that are
thc most medically appropriate and cost-cffcctive to bcst
serve the health interests of a given population.
This review of formulary systems covers their history,
structure, positive and negative outcomcs, and possible
future directions.

HI

Formularies were t i n t developed in hospitals during the

I9Xh The pharmaceutical market was experiencing
362

unprecedented growth. For example, 17 different companies were marketing 45 different oral penicillin preparations.21 Institutional policies were developed that
allowed pharmacists to dispense a generically equivalent
drug for a brand name product prescribed by physicians.
The pharmaceutical industry and physicians, rcpresented by the National Pharmaceutical Council and the
American Medical Association (AMA) respectively,
successfully worked to get state laws passed forbidding
this substitution by pharmacists. While community
pharmacists complied, hospital pharmacists resisted. In
the late 195Os, the American Society of Hospital
Pharmacists (ASHP) published a set of minimal standards
for pharmacies in hospitals with guidelines for their
interpretation. Among the standards developed was a call
for the implementation of a forinulary system. Interestingly in 1959, the successful launch of anothcr ASHP
publication, the American Hospital Formulary Service, a
reference book reviewing the key characteristics of drugs,
greatly advanced ASHPs financial status and added to
the organizations sphere of influence.
By the 196Os, many hospitals were successful in
developing institutional procedures that gave prior
consent for physician authoriLed pharmacists to select
generic alternatives under what was called a formulary
system. The American Hospital Association (AHA) and
ASHP issued joint statements on the legal basis of a
hospital formulary systcm and the guiding principles for
operating it. A fcw years later, the AMA and APhA
participated with AHA and ASHP to revise the guidelines
to the mutual satisfaction of all parties in a way that
would not alienate the pharmaceutical industry.
In 1965, two significant actions occurred that promoted
formulary systems. Medicare administrators borrowed
freely from ASHPs publications to create standards for
institutional health care resulting in a Medicare bill listing
the use of a formulary system among the eligibility
requirements of Medicare reimbursement. Also, the Joint
Commission required an active pharmacy and therapeutics (P&T) cotnmittcc for hospital accreditation.
Even with these supporting documents and accrcditation standards, adoption of lhrmnlary systems was not as
fast as many anticipated. In the 1970s, two surveys
rcvcalcd surprising results. In the first, of the 172
Encyclopedia o/ Cliniml Pharnzacy
DOT: 10.1081/E-ECP 120006321
Copyright B 2003 by Marcel Dekker, Inc. All rights reserved.

Formulary Systems

Medicare-approved hospitals responding, 3 1 did not have

a formulary system in place even though Medicare
required one.r51The second, looking at academic medical
centers with 500 beds or more, found that the majority of
formularies analyzed were simple drug lists and were not
used to guide prescribing decisions.[61
As the value of formulary systems became apparent,
their acceptance grew, at first just in the hospital setting
but later expanding to ambulatory sites. In 1986, the
Pharmaceutical Manufacturers Association officially accepted the concept of therapeutic interchange for hospital
inpatients, but opposed its use in other settings. The AMA
released a policy on drug formularies and therapeutic
interchange in both inpatient and ambulatory care settings
in 1994.[] This brought the AMAs views on formularies
into close alignment with ASHP. In the most recent
survey of pharmacy practice in acute care settings, more
than 90% of health-systems had P&T committees
responsible for formulary system development and management.@] Pharmacy directors reported using pharmacoeconomic and therapeutic information in their systems
formulary development process. Today, drug formulary
systems are considered an essential tool used routinely by
health plans, pharmacy benefit management companies,
self-insured employers, and government agencies.

The development of a formulary system within an organization rests with a multidisciplinary committee. In the
hospital and health system setting, this is typically called
the P&T committee. Virtually all hospitals and healthsystems have a P&T committee.[81 P&T committees usually meet six to eight times annually. An ASHP Position
Statement on formulary management declares that decisions should be based on clinical, quality of life, and
pharmacoeconomic factors that result in optimal patient
care.[] It advises against decisions solely based on economic factors. The Position Statement also recommends
that decisions must include active and direct involvement
of physicians, pharmacists, and other appropriate health
care providers. This may include dieticians, nurses,
administrators and quality management coordinators.
Formulary system management falls into three general
categories: drug selection for formulary inclusion, formulary maintenance, and medication use evaluation.

Drug Selection
Drug evaluation for inclusion on a formulary should
involve a careful assessment of scientific evidence, in

363

particular, peer-reviewed medical literature, including

randomized clinical trials, pharmacoeconomic studies,
and outcomes research data. If a drug is a new pharmacologic class, unlike any other available drug, the
review will fQCUS on efficacy, safety, and the potential
value to the organizations patient population. For drugs
that are additions to an existing pharmacologic class, the
evaluation takes on a more comparative nature. Reviewers
look for studies that compare the new agent to the agent
currently listed on the formulary. If these are limited or
unavailable, the comparisons are difficult and more
subjective. If two agents appear similar in all clinical
respects, the decision may be a financial one. This process
often results in class review as described later. Reviewers
must remember that new agents coming on the market
have been tested in a limited number of patients. Because
a drugs full adverse effect profile may not be evident
when first released, many committees choose to stay with
the older drug already listed on the formulary until
sufficient information is published.
Two key components of formulary drug selection are
generic substitution and therapeutic interchange. Generic
substitution is the substitution of one drug product for
another when the products contain the same active
ingredients and are chemically identical in strength,
concentration, dosage form, and route of administration.
The formulary will list the drug by its generic name,
strength, and dosage form. The product dispensed will be
the least expensive one. As the price of products change,
the product dispensed may change as well. When this
occurs, the pharmacist should inform the patient if the
physical appearance (e.g., color, tablet size) of their
medication has changed. The patient should be assured
that the new medication is identical to the previous one.
Therapeutic interchange is more complex that generic
substitution. The AMA defines therapeutic interchange as
the authorized exchange of therapeutic alternates in
accordance with previously established and approved
written guidelines or protocols within the formulary
system.71 Therapeutic alternates are drugs with different
chemical structures but which are of the same pharmacologic and/or therapeutic class. They can be expected to
have similar therapeutic effects and adverse reaction
profiles when administered to patients in therapeutically
equivalent doses. The AMA does not support therapeutic
substitution defined as dispensing a therapeutic alternate
for the product prescribed without prior authorization of
the prescriber. Therapeutic interchange in institutional
health systems has been used successfully for years.
Working out an acceptable procedure for therapeutic
interchange by the P&T Committee may be easier in this
setting. Therapeutic interchange in outpatient drug
programs in less structured ambulatory and managed

364

care settings may be more difficult and has been

criticized.['']

Maintaining a formulary is an ongoing process. Policies

and procedures for requests to add and delete drugs from
the formulary must be in place. This includes changing
recommendations for therapeutic interchanges and components of drug use guidelines. As the medical evidence
changes in the published literature, the formulary system
must be able to quickly respond.
Therapeutic class reviews are an important part of
formulary maintenance. The pharmacologic class of drugs
selected for review should be prompted by criteria set by
the P&T Committee."'] These criteria may include the
number of adverse drug reaction reports, new information
in the medical literature, or drug class expenditures. Some
groups may choose to review the class whenever a request
is received to add a new drug from that class to the
formulary. The goal is to always have the best agents
within a class available based on the latest medical
evidence. At the time of the review, new drug use or
treatment guidelines may be considered.
The formulary system should include a mechanism for
patients to receive a drug not listed on the formulary if it
is truly needed. A review of these non-formulary drug
requests may offer insight into areas where the formulary
is not meeting the needs of the health system's patients.
This is true if the review reveals that requests for a
specific agent are justified and frequent. The review may
show that education is needed for the prescriber to steer
them toward a more rational formulary choice.

Medication use evaluation (MUE) is a performance improvement method that is an important part of the
formulary system. MUE focuses on evaluating and improving medication use processes with the goal of optimal patient outcomes.''21 It involves establishing criteria.
guidelines, treatment protocols. and standards of care for
specific drugs and drug classes and the medication use
process (prescribing, preparing and dispensing, administering, and monitoring).

The description of the formulary system leads one to

believe that it would lead to positive outcomes. In the
hospital setting, a significant association has been shown

Formulary Systems

between decreased costs and a well-controlled formulary,

therapeutic interchange, or both."31 Hospitals that used
either strategy spent 10.7% less for drugs than those that
used neither. Hospitals using both spent 13.4% less than
those that used neither. An estimated $100 million in
pharmacy expenditures was saved by the Department of
Veterans Affairs (VA) in two years by implementing a
national f ~ r m u l a r y . " ~A] committee of the Institute of
Medicine found that for inpatient discharges for conditions likely to be affected by the VA formulary's limited
drug list, no increases in hospitalizations were found.['51
The committee did recommend to increase physician
representation on formulary committees and to abandon
the requirement that a drug be marketed in the United
States for a year before it could be admitted to the
formulary. However, convincing research clearly documenting improved patient outcomes is scarce.
Managed care organizations have used formularies to
rein in drug costs but a controversial study concluded that
formularies produced an opposite effect."61 Researchers
found that restrictions on drug availability were linked
to increases in other services shifting costs by increasing the use of either nonrestricted drugs or other health
care services. This study included the use of the restriction method called prior authorization, a method used to
discourage the routine use of an expensive drug by
requiring an approval process before the agent could be
prescribed. In general, the results showed that the more
restrictive the formulary. the higher the drug costs and
the higher the number of prescriptions, outpatient and
emergency room visits, and hospitalizations per patient
per year. The study design and conclusions have been
highly ~riticized."~]
A prior authorization technique involving non-steroidal anti-inflammatory drugs (NSAIDs) in Medicaid
patients was shown to be highly effective."81 NSAIDs not
available generically were place on prior approval status.
This lead to the increased use of generically available
NSAIDs as first line therapy. For a two-year period, the
result was a 53 percent decrease in expenditures (S12.8
million) with no concomitant increase in Medicaid
expenditures for other medical care.

Few ethical questions have been raised in the hospital

setting but in the outpatient setting, there may be concerns. Health plans may try to manage pharmacy costs by
offering incentives to physicians for prescribing lower
cost drugs. This may be depicted as unethical because the
strategy appears to be purely cost driven and possibly

365

lowering the quality of carc. owever; such incentives

may improve quality. For example rewarding physicians
guidelines for treating hypertension
-blocker and a generic thiazide).""'
In presentation at the Joseph A. Oddis Colloquium on
Ethics, it was suggested that the pharmacist play the role
of a pharmacoethicist on P&T

9.
10.

11.
12.
I.

http://www.ashp.org/public/news/breaking/DF-fix.pd~
esscti October 2000).
2. Higby, G.J. Amcrican pharmacy in the twenticth ccntury. Am. 3. Hcalth-Syst. Pharm. 1997. 54 (16), 18051815.
3. Talley, C.R.: Oddis. J.A. In uences and Achievements.
Am. J. Flcalth-Syst. Pharni. 1 97. 54 (16). 1815 1825.
4.
,pita1 Pharmacists: A history. Am. J . Nosp. Pharm.
3. 5 0 (SUPPI. 2). S1-43.
5.
aiids. T.F.: Williams, K.B. How drugs attain formulary

13.

14.

15.

16.
17.
18.

6. Kuckcr, D.T.; Visconti, J.A. Hospital formularics: Organd supplementary components. Am. J.
33 (9). 912-9i7.
7. Amcrican Mcdical Association. AMA policy on drug
forniularics and therapeutic interchange i n inpaticnt and
ilatory patient care settings. Am. J. Hosp. Pharni.
. 51 (14). 1808-1810.
8. Ringold, D.J.; Sanicll, J.P.; Schncider, P.J.; Arcnherg, S.

19.

20.

ASHP national survey of pharmacy practice in acute care

scttings: Prescribing and transcribing--1998.
Am. J.
Health-Syst. Pharrri. 1999. 56 (2). 142- 157.
http://www.ashp.org/bestpracticcs/forinulary/position/
positioi~pdf(accesscd December 2000).
Carroll, N.V. Formularies and therapeutic interchange: The
health care setting rnakcs a difference. Am. J. Health-Syst.
Pharm. 1999, 56 (5). 467 472.
org/bestpracticcs/formulary/gui dc/
esscd December 2000).
http://www.ashp.org/bestpractices/formulary/gui~le/
mcdication.pdf (acccssed December 2000).
FIarlct, T.K.: Hu, T.W. Association bctween forrnulary
strategies and hospital drug expenditures. Am. J. Mosp.
Pharm. 1992, 49 (9). 2207-2210.
Anon. National formulary a plus for VA. Am. J. HealthSyst. Pharm. 2000. 57 (14). 1302.1309,
http://books.nap.edu/catalog/9879.htinl
(accessed Dcccnibcr 2000).
Horn, S.D. Unintended consequences of drug formularics.
Am. J. Health-Syst. Pharm. 1996 5 3 (18), 2204-2206.
Curtiss, F.R. Drug formularies provide path to best care.
Am. J. Health-Syst. Pharm. 1996, 5 3 ( I X ) , 2201-2203.
Snialley. W.E.; Griffin, M.R.: Fought, R.L.:Sullivan, L.;
Ray, W.A. Effect of a prior authorization requirement on
the use of nonsteroidal anti
aid patients. N. Engl. 1 . Me
Smartwood, D.E. Ethics and managed care forinularics.
Am. J. Health-Syst. Pharm.
Jonscn, A. Fortresses and formularies: Ilrugs, ethics, and
managed care. Am. J. Health-Syst. Pharm. 2000, 57 (9),
853-856.

PHARMACY PRACTICE ISSUES

Thc O h i o State University, Columhus, Ohio, U.S.A

olesar
Univer.sity of Wisconsin, Madison, Wisconsin, U.S.A.

I
Extraordinary i n its scope and significance, the human
genome project (HGP) has revealed the complete 3 billion
base pair sequcncc that includes the estimated 35,000
genes of the human genetic blueprint.
One important outgrowth of the HCP is the development of technologies for thc transfer of therapeutic
genes to humans. Undoubtedly, improved biomedical
technology, coupled to a better understanding of the
genetic basis for most human discases, is resulting i n the
rapid identification of new disease targets and the development of innovative gene therapy strategies.l
The numbcr of clinical trials involving human gene
therapy has dramatically increased since the initiation of
the first approved trial in the United States to treat
adenosine deaininasc (ADA) deficiency in 1990.Since
this time, more than 3500 patients have been enrolled in
trials worldwide, with more than 2400 in the United
States.I4 The pharmaceutical industry is actively supporting gene-based therapy by investing billions of dollars, and most major academic medical centers have developed gene therapy programs. The majority of active
trials involve gene therapy for malignancy (6X%), AIDS
( I 8%), and cystic fibrosis (8%1).~
Valuable experience has been gained through rccipients of gene therapy, documenting the technical feasibility of human gene therapy and demonstrating, in most
trials, a relative lack of treatment-related advcrsc effects.
In particular, patients receiving both ex vivo gene therapy,
a procedure whcrc cells are removcd, transfected, and
placed back into thc host, and in vivo gene therapy, in
which the gene vector is placed directly in the patients
body, have tolerated the administration procedures
without acute adverse effects. Despite this, closc attention
has focused on thc relative lack of proven efficacy from
preliminary phase 1 and 11 trials. In gcneral, clinical trials

Encjc~loi~ediii
of Clinird Phcirinac.j
DOI: 10.1081IE-ECP I20006217
Copyright 0 2003 h y Marcel Dekker. Iiic. All rights reserbed

have demonstrated short-term expression o f the gene

product, overall low efficiency of gene expression in the
tissue(s) of interest, and lack of clinical efficacy. For these
reasons, the entire field of g e m therapy has been critically
evaluated at the National Institutes of Health (NIH). In
particular, conclusions from one panel strongly encouraged a redirection back to basic scientific research, with a
particular emphasis on improving vector design.

Gene delivery is the introduction of genes or cells containing gcnes lorcign to the human body for thc purposes
o l prevention, trcatment, diagnosis, or curing disease.
The introduction of exogenous deoxyribonucleic acid
(DNA) into mammalian cells for therapeutic intention can
be accomplished by several techniques that includc
physical, viral, and nonviral methods, each with advantagcs and disadvantages. The majority of clinical experience is derived from viral and nonviral vectors and is
therefore discussed. In all cases, several fundamental attributes are required for a gene therapy vector to be suitable for human use. The vector should be safe to the
recipient, capable 01efficient gene delivery and expression in the targeted tissue, and capable of mass production for human use. Based on these major criteria, the
ideal gene delivery system has yet to be identiried. Of
the more than 425 clinical trials conducted worldwide,
the field remains dominated by retroviruses (37.6%),
adenoviruses (20.2%): and plasmid-based, nonviral vectors such as catioiiic liposomes (1 7.6%).4 Numerous
other vectors and techniques are being used in phase 1
trials, but alone thcy do not comprise greater than 5%

367

Gene Therapy

368

le 1 Comparison of viral transfer techniques

etrovirns
Genome transfer
Virus titer
Purification
Maximum size
In vivo
Integration
Efficiency
Safety issues
Nondividing
Limitation

RNA
lo6- 109
Difficult
8 kB
NO

Yes
High
Mutagenesis
No
Cell division required

Adenovirus
DNA
10"- 1oI2
Yes
8 kB
Yes
No
Very high
Immune reaction
Yes
Transient expression

Liposome
DNA
NAa
Yes
50+ kB
Yes
Low
Moderate
?

Either
NA
Yes
50+ kB
Yes
Low
Low

?
?

Low efficiency

Low efficiency

Key: DNA. deoxyribonucleic acid; RNA. ribonucleic acid.

"NA. not applicable.

of the market share and therefore are not reviewed. Each

of the three major categories of vectors used in clinical
trials has unique attributes and limitations that include,
but are not limited to, DNA-carrying capacity, tropism
for target cells, in vivo transfer efficiency. duration of
gene expression, and potential to induce inflammation
(Table 1).

The fundamental goal of gene therapy is to correct a

singular genetic defect in the cells responsible for causing
disease in the host. To accomplish this, the gene of
interest must be isolated and packaged into a delivery
vector and then introduced to the recipient. The the-

rapeutic gene must enter into the cell intact and travel to
the nucleus where it interacts with the host cell machinery, ultimately being turned into a therapeutic protein
(Fig. 1). A major limitation of most gene therapy is poor
transfer efficiency of the gene to the target cell population. To overcome this obstacle, scientists have turned
to the most efficient, naturally occurring gene vectors
known to human kind-viruses. The primary objective is
to produce virus-based vectors that retain the essential
"gene delivering" features. while also eliminating characteristics associated with infection and host toxicity. Due
to the pathogenic nature of viruses, substantial effort has
also been devoted to the development of synthetic vectors
that chemically mimic the natural gene delivery features
of viruses. The most common viral and nonviral vectors
used in clinical trials share certain attributes but are quite
distinct in many ways. As is discussed, these features
have a substantial impact on therapeutic strategies and, in
certain situations, limit the use of vectors in different
disease states.

etroviral Vectors

Fig. B

Overview of gene therapy.

Retroviral vectors work by reverse transcribing their viral

ribonucleic acid (RNA) genome, which includes the
therapeutic gene insert, into a double-stranded DNA that
becomes stably incorporated in the host cell genome
The virus components associated with rep(Fig. ?.)."I
lication are removed, thereby preventing infectious risk
to the host and providing space for the inserted gene.
The simplest type of retroviral construct is the single
gene vector. In this system, the entire gene cassette of a
functional gene is placed in the retroviral construct with
gene expression controlled by the retrovirus gene promotor. The most widely used retroviral vectors in cli-

Gene Therapy

369

New progeny virus particles each containing reverse transcriptase

Entry

16%

into cell and

_c_

Transcription bq host cell RNA Polymerase

makes many RVA copies

into host chromosome

Fig. 2 Overview of retroviral vector administration.

nical trials are the double gene constructs. They possess

the therapeutic gene, as well as a second marker gene,
such as the neomycin phosphotransferase gene. A significant advantage of the double gene construct is that
cells expressing the gene marker protein can be selected
in culture and then readministered to the patient. Retroviruses integrate the gene insert into the host cell so they
are particularly suited for chronic diseases that require
long-term gene expression to correct the disease phenotype.['] One of the biggest limitations of retroviruses is that
they are relatively unstable following systemic administration.[71 For this reason, most human applications
require removal of the target cells for ex vivo gene
transduction. Retroviral vectors also require that cells
undergo replication during transfection to stably integrate
the gene of interest. Therefore, most clinical protocols
involve induction of cell replication during ex vivo cell

culture to enhance transfection efficiency. However, many

cells exist in a differentiated state; that is, they do not
replicate and may not readily be removed from the host,
thereby preventing the use of retroviruses. An additional
theoretical limitation of retroviral vectors involves insertional mutagenesis. Integration of the genetic material is
random and may occur anywhere in the host genome. It is
therefore theoretically possible that random integration
could disrupt expression of other key proteins.

enoviral V e ~ ~ o r ~
The most extensively used adenoviruses are serotypes 2
(Ad2) and 5 ( A d 3 because both are not associated with
serious infectious disease in humans.['] Similar to
retroviral vectors, elements of adenovirus DNA genome
are removed to prevent replication once inside the

370

Gene Therapy

Packaging Plasmid

@=F5iE!
Retroyiral Vector

Dibision of Packaging \ ector

into Separate gag-pol and en\ for

/Transient Methodl

Tranfection with a \-ector Plasmid

Selection resulting in the

nroducer
line
final ~
~ cell
..
.~
~
~~
~
.~
.. ..
~

Genomes for 2-3 d

45

Recombinant Retrovirus is
secreted into the Media
For harvest

~~~

I
Recombinant Retrovirus is
secreted into the Media for hailis4

Fig. 3 Overview of gene therapy preparation.

mammalian cell. Removal of these elements also

provides space for insertion of a therapeutic gene
(Fig. 3). An additional reason for tailoring the
adenoviral vector genome is to eliminate the expression
of antigenic viral proteins that precipitate a host
inflammatory response. A distinct advantage of adenoviral vectors is that they have broad cell tropism and
can transfect nondividing cells. They can also be
administered systemically via the intravenous, intramuscular, and intranasal routes. From a formulation
standpoint, adenoviral vectors are superior because relatively high titers can be achieved (10" colony-forming
units/milliliter) to ensure convenient dosing in a
minimal volume. Despite these attributes, the adenoviral
vectors possess features that limit their utility. Unlike
retroviral vectors, the gene cassette resides in the
nucleus independent of the host cell genome. Because
stable integration is not achieved, expression of the

gene product is transient. This can be an advantage if

temporary expression will correct the defect; however,
in most strategies, persistent gene expression is required
to correct the underlying disorder. Therefore. maintenance dosing of the vector is required to sustain therapeutic benefit to the patient. In this situation, the other
major limitation of the adenoviral vectors, host toxicity,
becomes a c o n s i d e r a t i ~ n . ' ~ ~The
' ~ ' adaptive host response becomes important because memory is generated
against the vector, thereby amplifying the immune response upon repeat administration and reducing the duration of gene expression. For these reasons, substantial
effort is underway to eliminate adenoviral vector-induced inflammation by selectively removing key antigenic determinants associated with the host response. The
fundamental challenge is to make a safe vector without
removing the ability of the modified virus to efficiently
deliver its genetic payload.

Gene Therapy

Successful transfection depends on both the efficiency of

DNA delivery to the cell (e.g., the fraction of DNA getting
into the nucleus) and the efficiency of DNA expression
(e.g., the amounF of gene that is transcribed). In theory, the
nonviral vector systems are attractive candidates due to
their potential versatility. Despite their use in clinical
trials, the lipid-based systems have several drawbacks.
Many targeting strategies have been developed but few
have worked in vivo. Once the nonviral plasmid expression cassette enters the nucleus, it exists as an episome,
similar to the adenoviral vector; therefore, transient expression is achieved. In general, the lipid-based systems
have a superior safety profile and gene therapy recipients
tolerate high doses without any notable adverse events.
The "Achilles heel" of the nonviral vectors have been
inefficient introduction and expression of DNA into target cells when compared with viral vectors. Another major obstacle with these macromoiecular aggregates that
prevents efficient gene delivery in the host is opsonization.'"] They are recognized as large. hydrophobic macromolecules and are cleared within minutes from the
circulation. Therefore, the fundamental challenge of the
plasmid-based systems is to improve transfection efficiency in vivo. This will likely be achieved by incorporating more features of the most efficient gene delivery
systems, viral vectors, while also maintaining a superior
toxicity profile.

Large-scale production and purification of gene therapy

vectors is critical in advancing the clinical utility of this
new class of medicine. Under ideal circumstances, a
highly purified vector stock should be manufactured with
a relatively stable shelf-life, in a dosage form that is easy
to dispense and ultimately administer to the patient. The
ideal system does not cumently exist for any of the vectors
used in clinical trials."21
In general, vector production is analogous to generating a recombinant protein. The product is a macromolecule that must be derived from cultures of living prokaryotic or eukaryotic cells and purified on a large scale.
The viral components required during vector production
can be defined as cis and trans elements. Cis elements,
for example, transcription initation promotors, must be
carried by the virus itself. Trans elements are removed
from the original viral genome to eliminate infectious

371

risk but are required during production to formulate a

functional viral vector. The trans elements are provided
by a packaging mammalian cell line, thereby providing
the necessary elements to build a functional vector during viral production but without producing an infectious
viral particle. Distinct production, formulation. and patient administration skills are required for each unique
product. From a manufacturing perspective, no standardized test currently exists that can be used to predict
virulence or pathogenicity of each unique vector. Currently, each lot of vector must be individually evaluated
by the manufacturer. All vectors are tested on three basic
principles in preclinical development and large-scale
production before use in clinical trials. Each vector must
demonstrate evidence of safe vector system design, appropriate production of vector stocks under good manufacturing process guidelines, and documentation of
purity under good laboratory practice guidelines. One
review discussed this topic e~tensively."~]
The final product must be free of adventitious
agents that primarily include bacterial or viral pathogens and other biologic contaminates contributed during
cell culture, such as DNA from prokaryotic or eukaryotic host cells and endotoxin. Purity testing for these
factors must be performed throughout the production
procedure and meet defined criteria before administration into humans.
The formulation and packaging of gene delivery
vectors is labor intensive and places a potential burden
on this rapidly advancing field. Vectors currently used in
clinical trials are limited by short shelf-lives. The vector
is then provided to the investigator(s) as a frozen, readyto-use product typically in a glycerol-salt solution. The
vector must be handled as a biohazard, with strict safety
precautions enforced by all personnel prior to, during, and
shortly after administering the vector to the patient. Significant effort is under way to develop convenient dosage
forms for synthetic gene delivery vectors that will sustain
potency on the shelf and allow convenient production,
formulation, and patient administration. Therefore, this
class of vector has a distinct advantage over modified
viruses. Administration to the patient can be done either
in vivo or ex vivo as already described. The major advantage of ex vivo gene therapy is that it ensures delivery
of the gene to the intended cells. The major disadvantages include the amount of time, expertise, and specialized facilities required to accommodate this strategy.
In contrast, in vivo gene therapy involves direct administration of the vector into the patient, which is much
more convenient. However, this creates unique challenges
because the product must be received fresh, handled as a

Gene Therapy

372

biological hazard, and provided to the patient usually

within hours of receiving the product. Currently, no guidelines have been published to address the safe preparation
and handling of gene therapy products. Handling usually
requires that therapies are prepared in biological cabinets
under sterile conditions. Appropriate barriers, including
gloves, gowns, and masks should be worn by those preparing and administering the dose. Gloves and other supplies used in preparation should be autoclaved or decontaminated by ultraviolet light prior to disposal in
biohazardous waste containers. Patient secretions including blood, urine, feces, and respiratory secretions may be
decontaminated with bleach prior to disposal.

The pharmacokinetic and pharmacodynamic parameters

of gene delivery vectors are largely uncharacterized in
humans. However, essential concepts have been described
regarding the many unique aspects inherent to in vivo
distribution of macroparticulate DNA carrier systems. The
distribution of most vectors is predictable and, in most
cases, is limited by physical characteristics of a macromolecule. In general, all gene delivery systems are rapidly
cleared from the systemic circulation, within minutes,
after placement into the bloodstream. This often limits the
capability of the vector to transfect cells in the targeted
tissue. Fortunately, many of the vectors used in clinical
trials can withstand physical manipulation, allowing sitespecific administration in an attempt to enhance expression in defined tissues. Perhaps a greater challenge is to

determine how long a particular gene will be expressed in

a specific tissue once the vector has delivered the therapeutic gene to the targeted cells. Preliminary investigations have addressed this concern, but are limited to
theoretic calculations from in vitro data."41 Ultimately,
this information is essential to develop a gene dosing regimen for a given patient, vector, and disease. Many trials
involve treatment of chronic disorders, including AIDS,
malignancy, and cystic fibrosis in which the gene is being
delivered to differentiated cells with a limited life span.
Therefore, it is presumed that many patients will require
maintenance dosing of a vector to sustain expression of the
therapeutic gene product over time.
Monitoring clinical efficacy of gene therapy has received little attention. For example, in published trials
involving patients with ADA deficiency, the investigators routinely measured serum ADA protein concentrations to document sustained expression of the therapeutic
gene."'] In additional, the patients were extensively monitored for evidence of improved immune function and
decreased number of infections. In the case of cystic fibrosis, the cystic fibrosis transmembrance conductance
regulator (CFTR) protein is not released by transfected
cells and remains associated with the cell membrane in
patients. Knowles et al. had to physically remove nasal
epithelial cells and then use advanced molecular techniques to document protein expression and function.[l6'
Gene therapy strategies undoubtedly create unique challenges for the clinician trying to determine when the
next dose of a gene therapy vector should be administered. Measurement of sustained gene expression, or a
lack thereof, will likely become common laboratory

Table 2 Monogenic diseases: phase I and I1 ongoing gene therapy clinical trials as of February 1, 2001
Gene

Number of
open trials

Chronic granulomatous disease

Cystic fibrosis
Fanconi's anemia
Gaucher's disease
Hemophilia B
Hurler's syndrome
SCIDS

P41 phox
CTFR
FACC
Glucocerebrosidase
Factor IX
IDUA
ADA

2
10
1
1
1
1
5

SCIDS
Purine nucleoside
phosphorylase deficiency

MDR
PNP

Indication

1
1

Countries
U.S.A.
France, U.K., U.S.A.
U.S.A.
U.S.A.
China
U.K.
France, Italy, Japan,
Netherlands, U.K.
Netherlands
U.S.A.

Key: CTFR, cystic fibrosis transmembrane conductance regulator; FACC, factor C; IDUA, a-L-iduronidase: SCIDS, severe combined
immunodeficiency; ADA, adenosine deaminase; MDR, multidrug resistance; PNP, purine nucleoside phosphorylase.

Gene Therapy

373

procedure for gene therapy recipients and require specialized molecular assay techniques.

TH

bT

Monogenic, or single gene disorders, are rare hereditary

disorders usually identified in childhood. They represent
the purest approach to gene therapy, where potentially, the
correction of a single gene defect by gene therapy may
lead to correction of the disease state. The major limitation
of gene therapy for monogenic disorders is that the rarity
of these conditions limits the number of patients able to
participate in clinical trials. The majority of gene therapy
trials for monogenic disorders has focused on severe combined immunodeficiency syndrome (SCIDS)[7s1 and
cystic fibrosis (CF).[193201
In addition, small trials are ongoing in Fanconis anemia, hemophilia, and other diseases
(Table 2 ) .

s
Patients with SCIDS, a rare genetic disorder in which
ADA is absent, have a greatly impaired immune system.
The initial success in gene therapy came in 1989, with the
report of the successful transfection of the normal ADA
gene into T lymphocytes. In the two patients studied, both
had normal immune function restored without adverse
effects. Subsequent studies have demonstrated that both
stem cells and CD34+ umbilical cord cells can be engineered to produce ADA and restore immune function.
Although this disease is extremely rare, it represents the
first successful clinical use of gene therapy.[I7 I

CF should be the ideal candidate for gene therapy because it is a single gene defect and thus presents a clear
target. The main clinical problem is in the lungs, and the
likely target is the surface epithelium. Methods of topical
delivery to the airway surface are already well developed.
All the required components for gene therapy were in
place, and CF gene therapy progressed rapidly from preclinical to clinical studies. The gene, although large, could
easily be inserted into a virus or produced as a plasmid;
cellular studies showed that CFTR gene transfer could
produce functional chloride channels and subsequently
showed that cystic fibrosis cell lines could be corrected.
The next steps were the demonstration of relatively effi-

cient gene transfer to the airway epithelium using reporter

genes in rodents, followed by partial correction of the
disordered airway electrophysiology in CF mice. Clinical
trials soon followed and more than 150 volunteers with
cystic fibrosis participated. The results have been both
encouraging. as gene therapy appears to be possible, and
frustrating. as it just do not work that well. There is good
evidence of low levels of gene transfer and small changes
in ion transport, but progress has been hampered by inefficient gene transfer, immunity to viral vectors, and a
systemic inflammatory reaction provoked by plasmid
DNA, resulting in no clinical benefit to date.93201

ancer
In contrast to monogenic disorders, cancer is generally
caused by multiple genetic defects, providing no clear
single target for gene therapy. However, because cancer is
the second leading cause of death in the United States,
gene therapy is under intensive investigation. Rather
than correcting the multiple genetic defects found in
tumors, cancer investigators have generally investigated
approaches to conferring drug sensitivity, either by
transvecting tumor cells with a gene encoding an enzyme
such as herpesvirus thymidine kinase (HSV-TK)[] that
can metabolize a nontoxic drug to its toxic form (suicide
genes) or with p53 (Table 3).[221
The majority of gene therapy clinical trials are for
cancer, with trials ongoing for almost all types of cancers.
In addition, gene therapy for cancer is closest to the clinic,
with both p53 and HSV-TK gene therapy in phase 111
clinical trials (Tables 4 and 5).

SV-TK
The HSV-TK gene converts nontoxic nucleoside analogs
such as ganciclovir into phosphorylated compounds that
kill dividing cells. Therefore, cells genetically modified
to express the HSV-TK gene can be killed by the administration of ganciclovir.[211
This cytotoxic effect of transduced cells on nontransduced cells is termed the bystander effect.[231Because only
a small number of cells will be transduced with the
cytotoxic gene, when these cells die, they release toxic
products that in turn kill the surrounding (or bystander)
cells. The TK-ganciclovir approach is currently used in
several clinical trials for a variety of malignancies, including g l i o m a ~ . ~ ~
Adenoviral (Ad)-mediated intrapleural HSV-TK-ganciclovir gene therapy has been tested primarily in phase I
and I1 clinical trials in patients with mesothelioma,

Gene Therapy

374

Table 3 Oncology: phase I and I1 ongoing gene therapy clinical trials as of February 1, 2001
~

Number of trials

Gene

Breast
Cervical
CML
Colon cancer
Head and neck
Head and neck
Glioblastoma

c-erb-b2
HPV
HSV-TK
CC49 zeta TcR chimera
INF
IL-12
HSV-TK

Lymphoma
Lymphomas and leukemias
Melanoma

MDR I
Specific idiotype
IL-2

1
3
6

Melanoma
Melanoma
Melanoma
Melanoma
Melanoma
Melanoma
Mesothelioma
Metastatic cancer
NSCLC
NSCLC
NSCLC
O\ arian
01aiian
01arian, piostate. and breast
Ox m a n
Pancreas
Prostate
Prostate
Prostate
Prostate
Prostate
Renal cell
Renal cell
Superficial solid tumors

IL-7, IL-12, Gm-CSF

IL-4
GM-CSF
IL-6
HLA-B7/beta 2 micro
MART1 +gplOO
IL-2
IL2
P53
IL-2
GM-CSF
HLA-A2
P53
BRCAl
Mo\ -gamma
Cytochrome p450
IL-2
PSA
P53
GM-CSF
HSV-TK
IL-2 + HLA B7
HLA B7/Beta 2 micro
IL-2

3
2
1
1
2
2
1
2
1
1
1
1
2
2
1
1
1
3
I
2
1
1
2
1

glioblastomas, or ovarian cancer. The gene was administered intrapleurally in patients with mesothelioma or
oharian cancer and by direct injection during surgery in
those with glioblastomas. In most phase I trials, the doselimiting toxicity was not reached. Side effects have been
minimal and included fever. anemia, transient liver enzyme elevations, and bullous skin eruptions, as well as a
temporary systemic inflammatory respouse. Using RNA
polymerase chain reaction (PC ), in situ hybridization.
immunohistochemistry, and immunoblotting, HSV-TK
gene transfer has been documented in approximately
50% of patients. Clinical activity has been minimal, al-

Country
U.K.
U.K.
U.S.A.
U.S.A.
U.S.A.
U.S.A.
Finland, France, Spain,
Switzerland, U.S.A.
U.K.
U.S.A., U.K.
Germany, France, Italy,
Netherlands, U.K., U.S.A.
Germany
Italy
Netherlands
Poland
U.S.A.
U.S.A.
Australia
France, Switzerland
U.S.A.
U.S.A.
U.S.A.
Singapore
U.S.A., U.K.
U.S.A.
U.S.A.
Germany
C.S.A.
C.S.A.
C.S.A.
C.S.A.
U.S.A.
Germany
C.S.A.
Switzerland

though this may be related to the patient population studied, which is generally those with advanced refractory
disease. Ongoing approaches are evaluating gene therapy
in combination with chemotherapy.[241

P53
P53 is the most frequently mutated gene in human cancer,
with an up to 50% mutation frequency in solid tumors.
Most commonly. these genetic changes are missense
mutations in one allele, although deletions or chain termination mutations can occur.

Gene Therapy

375

Table 4 Oncology: phase I11 ongoing gene therapy clinical

trials as of February 1, 2001
Indication
Glioblastoma
Head and neck
Melanoma
Ovarian cancer

Gene

Number
of trials

Country

1
1
1

Multicountry
U.S.A.
U.S.A.

U.K., U.S.A.

HSV-TK
P53
HLA-B7/Beta
2 microglobin
P53

Key: HSV-TK, herpesvirus thymidine kinase

Table 6 Cardiology: phase I and I1 ongoing gene therapy

clinical trials as of February 1, 2001
Indication

Gene

Number
of trials

Coronary artery
disease
Coronary artery
disease
Peripheral artery
disease

VEGF

Finland

FGF

U.S.A.

VEGF

Finland, U.S.A.

Country

Key: VEGF, vascular endothelial growth factor; FGF, fibroblast growth

factor.

Because normal or wild-type p53 is important in cell

cycle regulation and apoptosis. restoration or modulation
of p53 function is under intensive investigation for cancer therapy, with the hypothesis that restoration of p53
function may make cancer cells more susceptible to
the effects of DNA damage inflicted by conventional
chemotherapy or radiotherapy and able to undergo apoptosis.r221Three main approaches are under evaluation.
First, there is virus-mediated gene transfer in which a viral
genome is engineered to contain foreign genes that are
expressed in the host cell genome after infection. Second,
there is the use of a cytolytic virus that can replicate only
in cells that lack p53 function, and by targeting such cells
could destroy tumors with mutant p53. Third, there is the
discovery or design of small n;olecules that can interfere
with the negative regulation of p53, pharmacologically
activating the p53 response.
A single clinical trial using wild-type p53 gene transfer
in nine patients with non-small cell lung cancer in whom
conventional treatment had failed has been reported.[251In
this study, the LNSX retroviral vector was injected di-

Table 5 Infectious disease: phase I and I1 ongoing gene

therapy clinical trials as of February 1, 2001
Indication
EBV and
CMV
HIV
HIV
HIV
HIV

Gene

Number
of studies

Country

CMV pp65

U.S.A.

HIV envhev

CD-zeta
TcR chimera
Antisense
to pol 1
Rev+pol 1

U.S.A.,
Switzerland
U.S.A.

U.S.A.

U.S.A.

Key: EBV. Epstein-Barr virus; CMV, cytomegalovirus; HIV, human

immunodeficiency virus.

rectly into the tumor either percutaneously with radiological guidance or via a bronchoscope. In situ hybridization and DNA PCR showed vector-p53 sequences in
posttreatment biopsies, and apoptosis was more frequent
in posttreatment than in pretreatment biopsies. No treatment-related toxicity was noted, and tumor regression
occurred in three patients. Further extensive trials of adenovirus encoding wild-type p53 are currently underway.
The DNA tumor virus adenovirus produces a 55-kDa
protein from the E1B region of its genome, which binds
and inactivates p53. It was hypothesized that an adenovirus lacking E1B would not be able to replicate in
normal cells but would in cancer cells lacking p53 function. For this reason, ONYX-015, an E1B gene-attenuated
adenovirus was compared with normal adenovirus in human and colonic cancer cell lines with and without p53
function. As expected, the ONYX-015 virus replicated as
efficiently as the normal virus in the cell line lacking
wild-type p53, but not in the line with normal p53 function.[261This vector is in early clinical trials.

~ a r d i o v a s ~ uDisease
l~r
Angiogenesis, or growth of new blood vessels, appears
essential in revascularization after myocardial infarction
as well as in treating coronary artery disease and peripheral artery disease. Therefore, cardiovascular gene therapy has concentrated on vascular endothelial growth
factor (VEGF) in these diseases[271(Table 6).

Familial homozygous hypercholesterolemia is a rare hereditary monogenic disorder caused by mutations of the
LDL receptor gene. Individuals have severe hypercholesterolemia associated with premature atherosclerosis. In
a single study, patients were treated with gene therapy

Gene Therapy

376

Table 7 Other ongoing gene therapy clinical trials as of

February 1, 2001
Indication

Amyotrophic
lateral sclerosis
Alzheimers disease

Gene

Studies

Countries

CNTF

Switzerland

Nerve
growth factor

U.S.A.

U.S.A.

U.S.A.

U.S.A.

1
1
1

U.S.A.
U.S.A.
Austria

Anemia of end-stage EPO

renal disease
Cubital tunnel
HIGF- 1
syndrome
Hip fracture
Parathyroid
hormone
Rheumatoid arthritis HSV-TK
Rheumatoid arthritis IRAP
Severe inflammatory IL-4 and IL-10
disease of rectum

Key: CNTF, ciliary neurotrophic factor; EPO, erythropoetin; HIGF,

human insulin-like growth factor: HSV-TK. herpesvirus thylimidine
kinase; IRAP, insulin responsive aminopeptidase.

with the LDL receptor. Expression of the receptor was

documented, but LDL cholesterol levels remained substantially elevated 3 to 6 months after gene transfer,
611 t27 vs. 550 t51 mg/dL, before and after gene therapy, respectively.[2x1

In a phase I evaluation, VEGF121.10 was administered

to 21 individuals by direct myocardial injection into an
area of reversible ischemia either as an adjunct to conventional coronary artery bypass grafting or as sole therapy via a minithoracotomy. There were no adverse
effects attributed to the gene transfer, and patients had
decreased angina.[291
Other trials of VEGF have been reported. A case report
demonstrated improvement in blood supply to an ischemic limb after intra-arterial gene transfer of a plasmid
encoding for VEGF.[301The use of a plasmid-based gene
delivery system, although inefficient, was reasonable in
this situation because VEGF is a potent secreted product.
A phase 1 trial of intramuscular delivery of a plasmidencoding VEGF in the setting of severe peripheral vascular disease was reported.[311 Gene transfer was performed in 10 limbs in nine patients with nonhealing
ischemic foot ulcers. Increased circulating VEGF levels
were demonstrated after intramuscular gene delivery. Various measures, including ankle-brachial index and magnetic resonance angiography, showed qualitative evidence
of improved distal flow in 8 limbs.

esistance (MDR)
In a therapeutic approach, stem cells may be isolated from
patients and genetically modified to express the MDR
gene.i321These cells are then retuned to the patient prior
to administration of chemotherapy, making the stem cells
resistant to chemotherapy.

ther Diseases
Formation of new blood vessels by the angiodan VEGF is
an experimental strategy for treating myocardial ischemia. The VEGF proteins function by interacting with
specific receptors on endothelial cells, which initiates a
cascade of events culminating in endothelial cell migration, proliferation, aggregation into tubelike structures,
and networking of the arterial and venous systems.[271
Gene transfer represents one approach to delivering an
angiogen to the heart in which the carrier DNA (cDNA)
coding for VEGF is delivered to the myocardium, with the
myocardial cells used to secrete the VEGF. Studies in
experimental animals have shown that replication-deficient, recombinant adenovirus (Ad) gene transfer vectors
are advantageous for delivery of angiogens such as
VEGF, in that Ad vectors provide a high transfection
efficiency, remain highly localized, and express VEGF
for a period of 1 to 2 weeks, which is sufficient to induce
collateral vessels to relieve the ischemia but not long
enough to evoke abnormal angiogene~is.~]

Gene therapy is under evaluation for many diseases,

ranging from rare inherited single gene defects to
common disease such as HIV. deafness, autoimmune
diseases, bone regeneration, and many others[4,33,341
(Tables 5 and 7).

The first death attributable to gene therapy occurred in

September 1999, when an 18-year-old patient with ornithine transcarbamylase deficiency died. apparently as a
direct result of the experimental gene therapy s t u d i e ~ . [ ~ * ~ ~ ]
This prompted two senate hearings and resulted in recommendation for implementation of new policies by the
Recombinant Advisory Council (RAC), Food and Drug
Administration (FDA) and NIH, which require earlier
review of researchers plans for monitoring safety and

Gene Therapj

quarterly meeting^.[^^-^^' A few of the safeguards implemented include thorough public evaluation of protocols
before investigational new drug assignment for FDA and
institutional review board (IRB) approval; the development of a single, uniform mechanism for reporting
adverse events to the RAC, FDA, and other relevant
agencies; establishment of a public database of all adverse
events; and nonparticipation of investigators with financial
interests in study outcomes in patient selection, the
informed consent process, and direct management of
clinical studies.
Further evaluation of this tragic event has identified
that vector-associated toxicity was not the sole cause for
this patients death. The FDA determined that human
subjects in this investigation were not adequately
protected and that there was substantial financial conflict
of interest. Subsequently, the NIH has discovered hundreds of unreported adverse events among volunteers enrolled in gene transfer experiments. These findings have
catalyzed broad examination of the entire clinical research
process, with the Secretary of Health and Human Services
calling for broad reforms in informed consent, clinical
monitoring, and conflict of interest.

Gene therapy is in its infancy. Early and ongoing success

in SCID, combined with promising studies in cardiovascular and oncology therapies, supports optimism for
these novel strategeis. However, several important issues
remain, including the best vector for transfer and appropriate protection for both patients and health care
providers. The Orkin-Motulsky report clearly stated that
significant problems remain in all basic aspects of gene
therapy. Major difficulties at the basic level include
shortcomings in all current gene transfer vectors and
an inadequate understanding of the biological interaction
of these vectors with the host.61 As such, the report
clearly identified key recommendations to ensure continued progress in this field. The recommendations were
to 1) continue research at the basic level to improve
vector design and studies that will further identify pathogenic mechanisms of disease, 2 ) improve trial design
with quantitative and qualitative assessment of gene
transfer and expression, 3) maintain adequate financial
support for gene therapy studies and promote interdisciplinary collaborations at the basic and clinical levels,
and 4) disseminate information to the public that clearly identifies limitations of the field as well as exciting
new discoveries.

377

Many new gene delivery vectors and protocols are

currently in developmental stages that aim to improve on
the earlier prototypes. The relatively small number of
vectors used in clinical trials underscores the complexity
of DNA delivery and our lack of knowledge about how
these macroparticulates are handled and expressed in the
human body. It is hoped that the recent reprioritization of
gene therapy studies will improve the design of vectors,
enhance our understanding of the biological interactions
between gene-carrying vectors and the body, eliminate
adverse events, and improve information gained from future clinical trials. Assuming these events occur, experts
still predict that gene therapy is still more than 5 to 10
years from routine use in patients.

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39.

PHARMACY PRACTICE ISSUES

Art

Wilkes Univcrsity, Willes-Barre, Pennsylvania, U.S.A.

I
All drugs that are approvcd for sale generally carry at least
two names. The drugs are given a proprietary or trade
name givcn by the company that first develops them.
These companies often are referred to as the innovator
company. The drug is igned a nonproprietary or generic
name, which is agreed to by the WHO lnternational
Nonproprictary Nomcnclature (INN) Committee and thc
U.S. Adoptcd Names Council (USAN). A new drug is
usually first marketed with some patent protection and at a
price that, at a minimum, recoups the cost of development
over the remaining life of the patent or othcr exclusivity
arrangement. Eventually, protection from competition is
lost to other pharmaceutical companies, often companies
or divisions of companies that specialize in marketing
off-patent drugs. These companies or divisions are called
generic companies. They can apply to thc appropriate
regulatory body such as thc Food and Drug Administration
(FDA) for permission to markct the same active ingredient
under its nonproprietary or generic namc. The generic
manufacturer is not required to do a cornpletc clinical trial
to prove effectiveness and safety because that has already
been well established for the drug. However, it is required
to show that the new drug product is equivalent to the
original drug product. For the purposes of this article, we
define the drug as the chemical that has the pharmacological effect and the drug product as a dosage form that
contains the drug and othcr ingredients or excipients that
allow thc formulation of thc dosage form. There is a large
economic incentive for the development of generic drug
products, cspecially for highly successful drug products.
The pharmnccutical company that first brought the product
to market maintains the price at the original level or higher
to continue the cash flow into the company. This allows
the other companies to develop a formulation of the drug
and to win approval to market with the knowledge that,
even at a fraction of the selling price of thc innovators
product, the company can make a good profit. Some
innovators defend their market share by arguing quality
and reliability. The FDA must act as an impartial arbitrator
of this debate. The debate is clearly about money, but is
argued in a scientific forum. The key qucstion is, Are we
Eizc\icloprdia of Clinical Pizar-incicy
DOI: 10.1081/E-ECP 120006417
Copyright 8 2003 by Marcel Dckker, Iiic. All rights reset-vccl

sure that the two products, if used in thc same way in the
same patient, will yield the same result. I f a drug product
is subject to this debate, thc innovator always says no
and the sccond and subsequent manufiacturers always say
yes. In the United States, the FDA scts the standards
against which the question is resolved, and scientists take
sides usually on the issuc of arc the current FDA
standards good enough. If the FDA givcs an A rating to
a drug product, it is in cffect telling the prescriber that the
drug product will yicld the same therapeutic and sideeffects profile as the innovator drug product. The Orangc
Book specifies the equivalence rating from the FDA.
Almost all generic drug products currently marketed are
rated A; the FDA has not approved a generic without an A
rating in decades. Finally, the consumer pays the price,
either in the unnecessarily high cost of drugs if
unnecessary studies are performed and gcneric competition delayed or in risky drug substitution if the FDA is too
relaxed in its standards. The tests required by the FDA
have changed over the years. They have become morc
proscriptive and are based on sound statistical grounds.
The FDA has also increased thc level of oversight of the
pharmaceutical companies that manufacture generic
equivalents of innovator products. Thus, the regulatory
process has become more stringent, and the level of
assurance that the public has that a generic product is both
safe and effective has gone LIP.The FDA has often statcd
that there are no known therapeutic failures from
switching among products that have been ruled as
equivalent by the FDA.

In the carly 1970s, most states had antisubstitution laws

that required the dispensing of the innovator product when
the prescriber wrote for a drug by trade name. Most
physicians had learned only thc tradc name of the drug
product, and these laws ensured that gcneric substitution
would be at a minimum (1). The Amcrican Pharmaceutical
Association (APhA) along with other groups pushed for
the repeal of these laws and opened the way for the growth
379

38

of the generic industry. The lack of bioequivalence data

available at that time led to the formation of the Generic
Drug Bureau within the Food and Drug Administration.
As a result of the efforts of that group, the FDA produced
a book, Appi'oved Drug Pi-oducts With Therapeutic
Equivalence Evaluations, in the late 1960s. This became
known as the Orange Book because of the cover color. The
book has been published annually with monthly updates.
The contents are now available on the FDA Website (2).
In 1984, the Drug Price Competition and Patent Term
Restoration Act was passed. This act. also known as the
Waxman-Hatch Bill of 1984. encouraged the development of new innovative drugs by established procedures,
extended patent rights, and facilitated the FDA approval
process for generic drugs (3). To address the first goal, the
law created a mechanism to extend the period of patent
protection for manufacturers of innovative new drugs
generally ensuring at least 5 years of market exclusivity
after approval. To address the second goal, the law
established an Abbreviated New Drug Application
(ANDA) for applications after 1962. Drugs chemically
equivalent to those previously approved by a full
application process need only be proven bioequivalent,
not clinically equivalent. Depending on the drug, proof of
bioequivalence can involve in vitro dissolution studies, in
vivo singie-dose bioavailability studies, in vivo multidose
bioavailability rtudies. or a combination of these.
However, in vitro dissolution studies alone are not
adequate proof of bioequivalence for purposes of an
ANDA.

The goal of the testing of generic products is not to

establish the clinical usefulness of the drug but only to
ensure that the generic product or new formulation has the
same relative bioavailability as or is bioequivalent to the
inno\ ator product.
Bioavailablity has been defined as a measure of the rate
and extent of absorption of a drug into the systemic
circulation after administration of a dosage form. An
intravenous i.v. dose is considered by definition to be
100% bioavailable. All other routes of administration will
produce a total bioavailability less than or equal to that of
the i.v. dose. Thus, only a drug that is completely absorbed
into the systemic circulation can have the extent of
bioavailability equal to the dose stated on the label. In
addition to the extent of absorption, the rate of absorption

Generic Drugs and Generic Equivalency

plays a key role when evaluating the potential therapeutic

impact of a particular dosage form. Knowledge of the time
to onset of drug action, which is directly related to rate of
absorption, is a significant concern, especially in acute
clinical situations such as asthma attack, hyperglycemic
shock, and pain.
The bioavailability of drugs from specific dosage forms
is affected by the nature of the inactive ingredients or
pharmaceutical excipients and the process used in its
formulation. (For additional information, see Bioavailability of Drugs and Bioequivalency in this Encyclopedia.)
When comparing similar dosage forms from different
manufacturers or different lots from the same manufacturer, it is most useful to determine the relative
bioavailability of the two products or lots. Some scientists
have attempted to establish an in vitro test that could
successfully predict in vivo bioavailability. However, to
date, none has been developed.
Pharmacokinetics means the application of kinetics to
drugs. It can be defined as the study of the time course and
fate of drugs in the body. Teorell is often given credit for
the origin of pharmacokinetics with his publications,
Kinetics of Distribution of Substances Administered to the
Body (4, 5 ) . This science is the theoretical support for the
use of bioequvalency testing to establish therapeutic
equivalence among dosage forms of the same drug. The
first approach to a pharmacokinetic understanding of drugs
in the body, called compartment analysis, considered the
body as a group of compartments through which the drug
must pass. The compartment itself does not exist but
represents the average of many processes that give rise to
the observed phenomenon. The size of the imaginary
compartment can be calculated and is useful in understanding the process of absorption, distribution, and
elimination or metabolism of the drug. Regardless of the
model used, a plot of the plasma concentration of the drug
versus time yields a curve that can be described by a
polyexponential equation. The area under that concentration-time curve (AUC) is directly related to the amount
of drug absorbed. The time to reach peak concentration
and the peak concentration itself are related to both the
dose and the rate of absorption.
An important limitation of compartment analysis is
that it cannot be applied universally to any drug. A
simpler approach that is useful in the case of
bioequavalency testing is the model independent method.
It is based on statistical-moment theory. This approach
uses the mean residence time (MRT) as a measure of a
statistical half-life of the drug in the body. The MRT can
be calculated by dividing the area under the first-moment
curve (AUMC) by the area under the plasma curve
(AUC) (6).

Generic Drugs and Generic Equivalency

381

(See other articles in this Encyclopedia for more detailed discussion of these subjects.)

Drug products often undergo bioavailability testing in the

early stages of development. Changes in formulation
necessitated by results of clinical trials or stability testing
or changes in the availability of excipients or changes in
suppliers of excipients often require that the manufacturer
perform a relative bioavalability or bioequivalency test to
ensure that subsequent lots of a product will yield the same
amount of active ingredient at the same rate as was
possible in earlier formulations.
Bioequivalency studies are usually performed on young,
healthy, male adult volunteers under controlled dietary
conditions and fixed activity levels. This is because the
goal of the study is not to establish the clinical usefulness
of the drug but only to ensure that the two formulations
have the same relative bioavailability or are bioequivalent.

When assessing bioequivalence, the following three

parameters that characterize the plasma or blood
concentration-time profile of the administered drug are
usually measured:

1. Peak height,,,C
,,
represents the highest concentration
of the drug in the systemic circulation;
2. Time to peak, t,,, represents the time for peak height
to occur after the drug was administered;
3. Area under the curve, AUC, represents the total
integrated area under the concentration- time curve.
The first two parameters are indicators of absorption
rate, whereas the third is directly proportional to the extent
of drug absorbed into the systemic circulation from the
dosage form. Figure 1 is an example of a concentrationtime curve for a single dose of drug to a subject.
Although it is theoretically possible to determine the
rate and extent of absorption of a drug by measurement
of the rate and extent of the appearance of the drug in
the urine, this is not considered as reliable a method for
evaluation of a drug products bioequivalency as are
blood level data. Thus, the studies commonly performed
to demonstrate bioequvalence fall into two catagouries:
single-dose and multidose or steady-state studies. There
are advantages and disadvantages to each. Single-dose
studies are less expensive and expose healthy volunteers

Fig. 1 Blood concentration curve.

to less drug during the course of the study. However,

these studies require more sensitive analytical methods
and have higher subject-to-subject variability. In both
cases, a cross-over study design is used to control for
sequence effects. The study is designed to control for or
take into account as many variables as possible. The
subjects are randomly assigned to groups. Blood
samples are obtained from each subject before dosing
and at fixed time intervals after dosing. Currently, the
data are then analyized using appropriate statistical
ANOVA. The results must meet FDA guidelines for
mean and 90% confidence interval for each of the three
key parameters. For oral solid dosage forms, the FDA
requires that for a product to be considered bioequivalent, the ratio of the parameter for the two products,
together with their 90% confidence interval, must fall
between 0.8 and 1.25, using log-transformed data. This,
in effect, means that drug products that differ by more
than 10% in their rate and extent of absorption will not
be approved as generic equivalents.

Two issues have been raised recently with regard to the

approval of generic drugs. The first has to do with the issue
of Narrow Therapeutic Index Drugs, and the second has
to do with the use of individual bioequivalence in place of
average bioequivalence. The former concern has been
addressed in detail by Drs. Benet and Goyan (7). They
concluded that narrow-therapeutic-range drugs were the
least likely to have therapeutic failures among generic

Generic Drugs and Generic Equivalency

382

drugs, with proof of bioequivalency. The use of average

bioequivalence data is under attack. This is because of the
concern that there might be a significant subject-byproduct interaction. Regulatory agencies now assume that
this is not the case (8). The advantage of using individual
bioequivalence studies is the reassurance that if subject/product interactions do occur, the study design would
control for them, and a more statistically valid measure of
the rate and extent of absorption of the drug from the two
product would be determined. Some of the disadvantages
associated with shifting from average to individual
bioequivalence testing are cost, numbers of subjects
needed, and diversity of the study population required.
[See other articles that address the impact of the new
metrics on the reliability and cost of the performance of
bioequivalence testing (9- 12).]

OMY

The modern generic drug industry in the United States

really only dates from the passage of the Waxman-Hatch
Act in 1984. Within 5 years of passage, generic drugs
captured 40% of the market for prescriptions written
inthe United States. Since that time, the generic drug
market share has stablized between 40 and 50% of the
prescriptions written. However, the dollars paid for
generic drugs are only 10% of the total sales of drugs in
the United States. That statistic alone tells us that the
consumer receives enormous benefit from the substitution of therapeutically equivalent generic drugs when
available.
A horrendous scandal hit the industry in the late 1980s,
wherein firms representing 75% of the production of the
generic industry pled guilty to one or more criminal
charges involving filing false applications with the FDA,
paying illegal gratuities to FDA personnel, and/or related
crimes to gain an unfair competitive advantage in the
emerging marketplace. Surprisingly, this scandal produced
only a small delay in the market share march of generic
drugs and only a temporary loss of consumer confidence in
generic products.
The scandal was tied to a phenomenon that still
dominates the business strategies of generic drug firms to
this day: the need to obtain approval to manufacture and
distribute before other firms enter the market. Because of
the commodity nature of the business and the relative
ease of entry into the industry, firms devote most of their
resources and managerial talent to obtaining first or second
approvals from the FDA for their products. Once a generic

drug has four or more competitors, it is no longer profitable

for additional generic companies to enter the market.
Generic drug manufacturers typically will continue to
manufacture drugs that produce little or no profit because
large purchasers that are their prime customers (chain
drugs stores, buying groups for smaller community
pharmacies, etc.) prefer to buy from companies that can
supply most of the common generic drugs. For example, if
a generic drug firm no longer produces amoxicillin
because it can make more money by shifting its antibiotic
production facilities to, for example, a cephalosporin drug
for which it has less competition, a large chain may chose
to buy its entire generic antibiotic line from another
company that supplies both.
The profitable generic drug companies are profitable
because they have found a strategy to maintain some
control over the price of their products. In the early years
(1984-1988), the best way to get first approval from
the FDA apparently was to be first to file, to get assays or
bioquivalence studies done on difficult to duplicate drugs,
or to find some way to get an expedited approval from
inside the agency. Unfortunately, this sometime involved
payoffs to FDA review chemists (those FDA experts
assigned the task of evaluating biostudy results, the
crucial piece of a generic drug application, remained
remarkably free of the scandal). More often, it involved
submitting false information to the FDA (including, in a
few cases, false biostudies). Many generic drug firms did
not survive the scandal, and others survived only after the
previous management and ownership were purged from
the firms.
For a short period, it was believed that the profitable
segment of the business involved not production but
distribution. After all, if commodity prices approach
marginal cost and the marginal cost of manufacturing
drugs is minimal, but the price to the consumer remains
significantly more than marginal, there must be middlemen somewhere making the money. Clearly, those
middlemen were not in the retail pharmacy where profits
continued to be squeezed. Distributors were thought to be
the new profit centers. But a funny thing happened on the
way to that particular bank.. . .
Consumers became outraged at the rapid increase in the
price of pharmaceuticals as the innovator companies (and
some generic firms) rushed to raise prices and as generic
drug company after generic drug company was pushed out
of the industry in the wake of investigations by a
Congressional committee and a federal grand jury.
Second, the Administration, in response to public concern
about the cost of pharmaceuticals, pressured the
pharmaceutical industry and forced lower prices and
significant rebates to the federal and state government

rugs and Generic Equivalency

programs that paid for drugs. Wholesale distributors of all

drugs subject to the federal rebates suffered.
Finally, the firms that thought they could profit most
from the scandal entered the market. These were
innovator firms, many of which had already played a
significant role in the distribution of generics.
Ultimately. the profit margins from generic drug sales
were not sufficient to carry the overhead of the branded
companies, and most left the market or returned to their
distributor role. Even in the case of the firms
manufacturing and marketing generic versions of their
own branded products, giving them significant advantage over the remaining pure generic firms in
developing and filing of the ANDAs with the FDA
and the added advantage of relatively less scrutiny from
the scandal-rocked agency, most had exited the
marketed by the end of the decade.
Some innovator firms entered the generic drug market
so that they could have a product line consistent with their
new business strategy: disease state management. This
strategy, a function of the rise of HMOs and the return of
the concept of scarcity to prescription drug dispensing,
was intended to involve the development of a continuum
of drug therapies for the treatment of a specific illness
(diabetes, depression, etc.), wherein the patient would be
tried on the older, less-expensive drug first and. if it did not
work. the next most cost-effective drug would be
administered and so on until the least cost-effective drug
would be the treatment of last resort. Unfortunately, the
branded companies that selected this strategy found
themselves competing with doctors. hospitals, and
insurance companies for control of the treatment regime
of individual patients, a losing proposition for the entity
with the least amount of information about and access to
the individual patient.
Another factor in reducing prices of all drugs that had
some form of competition was the rise of the HMO and its
pharmaceutical watchdog. the pharmacy benefit manager
(PBM). These PBiMs create a formulary of approved drugs
(drugs for which they would reimburse partially or fully)
based on bids from competing companies.
Much of the publics confusion regarding generic
drugs arose from a practice of the PBMs to pressure
doctors to substitute different chemical entities in the
same therapeutic class for the prescribed medicine. Such
a switch IS called a theraputic substitution as opposed to
the switching among manufacturers of therapeutically
equivalent drugs (generics and the innovator drug or
other FDA AB-rated substitutes). Therapeutic substitution involves a switch to a different drug, whereas
generic substitution involves a switch to the same drug
from a different manufacturer. If a patient is switched

383

between FDA AB-rated drugs, the FDA offers the

assurance that they can expect the same therapeutic
and side-effect profile as the brand drug or another
AB-rated generic drug. The FDA offers no such
assurance if the switch occurs among different drugs,
even if they are in the same therapeutic class. For
example, aspirin and Tylenol may be equally effective in
the treatment of headache, but the FDA makes no such
certification. whereas it makes exactly that certification
for Bayer aspirin and Safeway aspirin.
The dominance of the HMO (and related organizations) and their PBMs (and related organization types)
served to accelerate the substitution of generic drugs at
the turn of the 21st century. However, even that pressure could not slow the re-emergence of a high rate of
price increase, greater than consumer or comparable
wholesale prices as a whole, in prescription drugs.
Innovator companies learned that establishing very
high prices for breakthorough drugs could more than
compensate for the loss of patent protection on a highly
profitable drug.
Furthermore, the United States is the only developed
country in the world that has chosen not to explicitly control
the price of any drug product and has used its market power
as a huge buyer relatively sparingly. Consequently. U.S.
prices for drug products still under patent are usually
substantially above those charged anywhere else in the
world. Generic prices approach cost except for those few
generics that have managed to eliminate or limit for a
specific period competition from other generics.
Those generic drug firms that prospered in this
restrictive price environment all had one or more niche
drugs that were immune from corrosive price competition.
Some companies mastered a manufacturing process that
produced bioequivalent medicine that the innovator itself
found difficult to master lot to lot. Others took advantage
of certain exclusivity provisions in the law for those that
challenged a product patent in court, ostensibly to cover
the cost of litigation. In other cases, the settlement of those
cases provided some form of licensing or distribution
rights that permitted the sale of a generic product while the
patent was still valid. Finally, a fortunate firm might find
itself in possession of the exclusive right to purchase the
raw material from the only source available to generic
drug manufacturers.
All generic drug firms capable of generating the
necessary cash to develop and market new drugs are
moving toward that lucrative market. For the time being,
the United States has chosen to use the market mechanism
as its only important control on drug prices. Generics are
the competition, and competition is our only real form of
price control.

Generic Drugs and Generic Equivalency

384

According to the Congresslonal Budget Office (CBQ),

consumers saved $8- 10 billion in 1994 because of the use
of generic drugs. In that same 1998 report, CBO cited the
Waxman-Hatch Act, generic substitution laws passed by
the states, and government health programs as seminal
events leading to the acceptance of generic drugs and the
resulting savings.

5.

6.

I.
8.

Knoben, J.E.; Scott, G.R.; Tonelli, R.J. Overview of the

FDA Publication Approved Drug Products with Therapeutic Equivalence Evaluations. Am. J. Hosp. Pharm. 1990,
47 (12), 2696-2700.
Food and Drug Administration. Approved Drug Products
with Therapeutic Equivalence Evaluations; http://www.
fda.gov/cder/ob/ FDA: Rockville; Available from the
Government Printing Office: Washington, DC. 2000.
Weaver, L.C. Drug Cost Containment-The
Case for
Generics: Situation in the U.S.A. J. Soc. Admi. Pharm.
1989, 6 (l), 9-13.
Teorell, T. Kinetics of Distribution of Substances
Administered to the Body. 1. The Extravascular Modcs of

9.
10.
11.

12.

Administration. Archives Internationales de Pharmacodynamie et dc Therapie. 1937, 57, 205-225.

Teorell, T. Kinetics of Distribution of Substances
Administered to the Body. 11. The Intravascular Mode of
Administration. Archives Internationales de Pharmacodynamie et de Therapie. 1937, 57, 226-240.
Yamaoka, K.; Nakagawa, T.; Uno, T. Statistical Moments
in Pharmacokinetics. J. Pharmacokinet. Biopharm. 1978,
6 ( 6 ) , 547-558.
Benet, L.Z.; Goyan, J.E. Bioequivalence and Narrow
Therapeutic Index Drugs. Pharmacotherapy 1995, 15 (4),
433 -440.
Patnaik, R.N.; Lesko, L.J.; Chen, M.L. Individual
Bioequivalence. New Concepts in the Statistical Assessment of Bioequivalence Metrics. FDA Individual Bioequivalence Working Group. Clin. Pharmacokine. 1997,
33 (1). 1-6.
Midha, K.K.; Rawson, M.J.; Hubbard, J.W. Individual and
Average Bioequivalence of Highly Variable Drugs and
Drug Products. J. Pharm. Sci. 1997, 86 (1 i), 1193-1 197.
Snikeris,F.; Tingey, H.B. ATwo-StepMethodfor Assessing
Bioequivalence. Drug Inf. J. 1994,28 ( 3 ) , 709-722.
Holder, D.J.; Hsuan, F. A Moment-Based Criterion for
Determining Individual Bioequivalence. Drug Inf. J. 1995,
29 ( 3 ) , 965-979.
Mohandoss, E.; Chow, S.C.; Ki, F.Y. Application of
Williams Design for Bioequivalence Trials. Drug Inf. J.
1995, 29 (3), 1029- 1038.

PROFESSIONAL DEVELOPMENT

Virco L ' h Inc-., Rockville, Mnryland, U.S.A.

I
Approximately 7000 pharmacists serve the federal government in a variety of rolcs and organizations, including
the Department of Veterans Affairs (VA),the Department
of Defensc (DOD), and the U.S. Public Health Service
(PHS). Pharmacists in the uniformed services, Army,
Navy, Air Force, and PHS, may be either commissioned
officers or hired via the civil service system. Opportunities for clinical practice and research in the federal government represent a large, but relatively unknown option.

The VA health care system now includes 4000 pharmacists, 173 medical centers, nearly 670 outpatient and
community clinics, and 131 nursing home units. The VA
is affiliated with more than 1000 schools across the
United States, including pharmacy, medical, and dental
schools. Each year, approximately 100,000 health professionals receive training at VA medical centers. The VA
system has been a leader in opening new career pathways
for pharmacists that reward the achievement of exccptional skills. For example, pharmacists can receive increases in pay by complction of advanced degrees or by
ing the board certified pharmacothcrapy specialist
(BCPS) examination. There arc a number of programs to
provide additional training for VA pharmacists and transition them from distributive roles to clinical functions.
Veterans Affairs pharmacists serve in a number of
clinical roles including, but not limited to, pharmacistrun ambulatory clinics, members of intcrdisciplinary care
teams, patient education, pharmacokinetic evaluations,
therapeutic consultation, and research." These services
are providcd in various inpatient, long-term, and ambulatory paticnt care settings. Most clinical pharmacists
will have advanced professional degrees (M.S. or
PharmD.), postgraduate training, and/or sufficient professional experience. Clinical pharmacy specialists arc

'

Encjclopctiia of Cliiiical Phui-mucy

DOI: IO.IOXIIE-ECP 120006176
Published C 2003 h y Marcel Dekker, Iiic. A!I rights reserved

advanced practitioners who provide clinical services for

specialized services. These services include anticoagulation, psychiatry, geriatrics, diabetes, infectious diseases,
and medication refill. They also may have prescribing
authority within a defined scope of practice. There arc
185 pharmacy residency programs at VA medical centers, many with a strong emphasis on ainbulatory and
primary care.

The mission of the medical departments in the Army,

Navy, and Air Force is t o provide effectivc health care to
U.S. forces in times of conflict and to provide highquality health care in p e a ~ c t i m c . ' ~There
. ~ ' are currently
approximately 1500 pharmacists working in these units,
both as commissioned officers and civil service. Some
pharmacists within the armed services arc deployed with
troops to provide pharmacy services during training
missions or wars. Therefore, they must participate in
training exercises and workshops designed to simulate
these types of expericnces. Other pharinacists work at
military hospitals and outpatient clinics, providing more
traditional clinical pharmacy services. Pharmacists participate in a variety of clinical roles, including patient
rounds, drug information, and patient counseling. Some
pharmacists undergo a credentialing process that gives
them prescriptive authority and enables them to assumc
responsibility for the management of thc patient within
defined roles and limits. Armed services ambulatory care
pharmacists play activc roles in direct patient care within
such therapeutic areas as diabetes, asthma, hyperlipidemia, and hypertension.
Pharmacists within the Army are also members of a
bioterrorism readiness force that is prepared to respond
to medical emergencics arising from the terrorist use
of weapons of mass destruction. Many pharmacists
within thc armed services do not possess Pharm.
other advanced degrees, although therc is a strong coin385

Government, Clinical Pharmacy Careers in

356

mitment to support those individuals who pursue

additional education. There are a number of residency
and fellowship programs available to these pharmacists. and opportunities exist to attain a nontraditional
PharmD degree.

The PHS is organizationally part of the Department of

Health and Human Services.41Pharmacists are probably
most familiar with such agencies as the Centers for
Disease Control and Prevention (CDC). the Food and
Drug Administration (FDA), the Indian Health Service
(IHS). and National Institutes of Health (NIH). In addition, the PHS has memorandums of agreement with
the Federal Bureau of Prisons (BOP), Immigration and
Naturalization Service, and U.S. Coast Guard (USCG), to
provide primary health services. The Office of Emergency Preparedness and the National Disaster Medical
System are also located within the Department of Health
and Human Services.

rs d

r e v ~tnion

There are currently nine pharmacists who serve at the

CDC coordinating the CDC Drug Service, which distributes 13 special immunobiological materials and drugs
to physicians in the United States. Special biological and
antiparasitic drugs that the CDC distributes include botulism and diptheria antitoxin, bithionol. ivermectin. pentostam, and other medications with restricted usage in
the United States. These pharmacists also ensure procurement of drugs, maintenance of treatment investigational
new drug applications (INDs), and timely reporting to the
FDA. Other pharmacists who also possess a Masters
degree in Public Health perform epidemiology and field
work in foreign countries. The CDC has been charged to
maintain a stockpile of pharmaceuticals that can be immediately deployed in response to chemical or biological
terrorism events within the United States.

The FDA employs more than 250 pharmacists in all phases

of the agencys regulation of drugs, biologics. medical
devices, medical foods, and veterinary products. Pharmacists serve as reviewers for INDs. new drug applications
(NDAs), and generic drug approvals, evaluating the safety,

efficacy, packaging, and advertising of prescription and

nonprescription drugs. They are also involved in adverse
experience reporting and postmarketing surveillance, and
function in many other positions ranging from field inspector to project managers, which are the liaison between
the pharmaceutical industry and the FDA. Other pharmacists contribute to the FDA with respect to compendia1
standards, scientific investigations, manufacturing facility
inspections, and the FDAs research laboratories. In addition, they also work with expert advisory committees and
review panels. Most FDA pharmacists serve at the headquarters in Rockville, MD, but others are assigned to the
many regional, district, and local offices throughout the
United States that carry out inspection and enforcement
activities. A PharmD degree is preferred but not generally
required for many FDA positions.

Indian Health Service

The IHS employs more than 500 pharmacists who are
part of a health care team that provides comprehensive
care to 1.4 million Native Americans and Alaska Natives
in hospitals and ambulatory clinics in 34 states. The IHS
pioneered many of the clinical pharmacy services that
are now considered standard practice. Pharmacists have
direct access to the patients medical record to ensure
appropriateness of drug therapy, monitor for adverse
effects. and conduct activities in health promotion and
disease prevention. Indian Health Services pharmacists
have long been involved in expanded roles such as
primary care, and many have prescriptive authority under
medical staff protocols. They are actively involved in
drug selection, dosing. treatment, and evaluation of
therapy. Patient consultation has been an integral part
of the IHS pharmacy program for more than 30 years, and
private consultation rooms are used to promote effective
patient communication. The IHS offers three residency
programs: American Society of Health-System Pharmacists (ASHP)-accredited programs in pharmacy practice
and ambulatory care, and an American Pharmaceutical
Association (APhA)-accredited residency in community
pharmacy practice. The IHS also provides their pharmacists with the opportunity to pursue a PharmD degree
through a relationship with Idaho State University.

National institutes of
Opportunities for pharmacists exist in both the intramural and extramural programs. The extramural program accounts for nearly 90% of NIH funding and is

Government, Clinical Pharmacy Careers in

comprised of sites around the world, whereas the

intramural program is located on the NIH campus in
Bethesda, Maryland. The NIH Clinical Center is a 350bed hospital devoted exclusively to patients of the
intramural clinical research program. Its pharmacy is
supported by 50 pharmacists in various roles, including
nine clinical pharmacy specialists in the areas of
oncology, infectious diseases, critical care, bone marrow
and solid organ transplant, mental health, drug information, and ambulatory care. These pharmacists also serve
as principal and associate investigators in various NIH
studies. Clinical pharmacy specialists generally have a
PharmD degree and postgraduate training in residency
and/or fellowship programs. The staff also includes
pharmacists with expertise in drug formulation, study
design, analyticallquality control, and pharmacokinetics.
The NIH also offers four ASHP-accredited residencies.
There are also opportunities for radiopharmacists within
the NIH Clinical Centers Nuclear Medicine and Positive
Electron Tomography (PET) Departments.
The research program at NIH also uses pharmacists
in many of its 14 institutes. Pharmacists in the National
Cancer Institutes (NCIs) Pharmaceutical Management
Branch are involved in anticancer drug development,
protocol development, collection of clinical data, distribution of NCI investigational drugs and the Treatment
Referral Center. In addition, the intramural program of
the NCI has a pharmacokinetics laboratory where pharmacists perform basic and clinical research. The
National Institute of Allergy and Infectious Diseases
(NIAID) Division of AIDS pharmacists participate in
protocol development and implementation, and act as
consultants to more than 300 pharmacists involved in
NIAID-sponsored AIDS clinical trials.

The BOP employs more than 120 pharmacists who work

in both hospital and ambulatory settings in 99 prisons in
38 states. Pharmacists fill medication orders directly
from the inmates medical record, thereby having access
to full information on the patient. Pharmacists at the
BOP are significantly involved in monitoring compliance, managing drug therapy. ordering and interpreting
laboratory studies, and medication counseling for inmates in tuberculosis prophylaxis, mental health, HIV/
AIDS. and other more traditional chronic disease clinics.
Many pharmacists stationed in hospital settings have a
presence on mental health and medical/surgery floors,
round with physicians, and provide drug information
services to the medical staff. Pharmacists at the BOP are

387

also performing research in the area of patient counseling and compliance.

ast
Officers commissioned by the PHS deliver primary care
services to USCG members and their families at 26
shore-based sites. Sixteen active-duty, PHS- commissioned corps pharmacists are detailed to the USCG. In
the early 1990s, the USCG adopted the chart prescribing
and prescription dispensing model developed by the IHS.
The USCG pharmacy program is linked throughout the
United States to the DOD Composite Health Care System for computerized dispensing functions.

The PHS offers students in medicine, nursing, pharmacy,

and other allied health professions the chance to gain
career experience at sites throughout the United States
through a program called COSTEP. These salaried positions, available during vacation or elective time, provide
students with valuable experience and insight into career
opportunities within the PHS.

C
These programs represent the most common career paths
for pharmacists in the U.S. government. However, there
are additional federal agencies, such as the Centers for
Medicare and Medicaid Services, where pharmacists
serve in nontraditional roles. Although generally not
considered by pharmacy practitioners and students, the
federal government provides a number of innovative and
unique practice areas for clinical pharmacists.

* Pharmacy programs within the PHS and related links

http://www.hhs.gov/pharmacy/
* Links to numerous DHHS agencies
http:l/www. hhs.gov/agencies

Government, Clinical ~ ~ ~ a Careers

r ~ ain c ~

388
e

VA
http://www.va gov

U.S. Public Health Servicc Commi\sioned corps

http://www.usphr.gov
@

U.S. Army Pharmacy

http://armypharmacy .org
U.S. Air Force Pharmacy
http://www.af-pharmacicts. or&/

U S. Navy Pharmacy
http://navymedicine med navy. mil/navypharmacy

DOD Pharmacoeconomic Center

http://www.pec.ha. osd.mil/

NIH Pharmacy Department

http://www.cc.nih.gov/phar

@den, J.E.; Muniz. A,; Patterson, A.A.; Ramirez, D.J.;

Kizer, K.W. Pharmaceutical services in the department of
Veterans Affairs. Am. J. Health-Syst. Pharm.
761 - ~ ~ 7 6 5 .
2. Williams. R.F.; Moran. E.L.; Bottaro, S.D., 11; Dydek; G.J.;
Caouette. M.L.; Thomas, J.D.; Echcvarria. R. Pharmaceutical services in the United States army. Am. J. HcalthSyst. Pharm. 1997. 54 (7); 773-778.
3. Young, J.H. Pharmaceutical services in the United States
air force. Am. J. Health-Syst. Pharm. 11999, 54 (7), 783786.
4. Paavola, F.G.; Dermanoski, K.R.; Pittman. R.E. Pharmaceutical services in the United S
Service. Am. J. Health-Syst. Pharm.
772.
1.

PHARMACY PRACTICE ISSUES

ea
Templc University, PhiLidelphia, Pennsylvania, U.S.A.

Merc k RC Co. inc., Whitehouse S h l i o n , N e w Jersey, U.S.A.

I
It is quite fascinating how the organization, structure, and
financing of health care services can be so very diverse in
different countries around the world. One might think that
leaders and policymakers would be aware of each others
national health systems and, by emulating the best
features, that they would tend to move toward harmonization and greater similarity.
umptions is false. National hcalth
care systems vary widely and are more related to
variables in each country (1). In Fact, the hcalth system
in a given country is a mirror of how that society
functions at large. Health care delivery systems must be
compatible with thc: 1) economic system: socialist,
capitalist, or mixed; 2) political .system: major or minor
role of dcgree of government centralization; 3) wealth qf
the country: use of primary care facilities, access to
specialists and tertiary care facilities; 4) tmditinn.v and
conventions as ,seen in theiv history-fundamental,
visible things are difficult to change; 5) geography:
whether the majority of the population is located in a
few metropolitan arcas, with the remainder scattered in
rural areas, or whether the population is spread over
hundreds of islands; 6) injhtructure: roads, communication systems, and air service; and 7) extent of and
belicj in high teclznology (2).
There are other factors as well: the system from a
previous colonial power, extent of literacy and
education, and relationships with outside countries, to
name a few.

The remainder of this article examines the hcalth care

delivery cystem\ i n six very different countries. Even
though Canada and the United Statcs are similar countries
with a shared border and language and with open
1h:vcloprdicz o j Cliiiir.ol Phcir-nzcq
D01: 10.1081/E-ECP
120006421
Copyright 0 2003 by Mai-ccl Dekker, lnc. All rights reservcd

communication, their health care delivery systems could

not be any more diffcrent. Each side of the border is aware
of what happens on the other side, however, a series of
complex and powerful forces keep them moving in their
own directions.
We look at six countries very briefly in this article to
highlight the incredibly diverse approaches to health
service organization and financing. In essence, most health
systems fit into one of the following models:
State ownership and control-The best examples are
the British National Health Service and the Swedish
system in which clinics, hospitals, and most service
providers are owned and operated by the government
(3).
State health insurance program-Here,
the govcrninent is the sole or major payer.
the facilities and resources are in nongovcrnment
hands. This is the case in much of Europe (4).
Mixed system-This is seen in much of Asia and
Central America and usually where there is a small
wealthy class and a massive lower class. The lower
class receives care from public facilities, and the small
upper class uses private-sector, fee-for-service, and
self-paid care.
Other scenarios fit into this category as well. The
United States has several independcnt health care systems
including the military, veterans, Medicaid (a federal
program for the medically indigent), Medicarc (a federal
insurance program for those 65 years of age and older),
private-sector for-profit, and not-for-profit clinics, hospital chains, managed-care organizations, religious,
prison health, and university teaching facilities ( 5 ) .
4. Exclusively private sector-This category is shrinking as nations realize that health maintenance and
disease prevcntion/wellness are important to their
national goals of strength and productivity. Switzerland would still fit into this category, where most
health care resources are in private hands (6).
389

Health Care Systems: Outside the United States

390

anada
Organization
Canada uses a national health service, which provides
medical services and hospital care to its entire population.
The individual provincial governments operate health
plans that conform to national legislation but can differ in
various aspects. This Medicare program guarantees
comprehensiveness, universal access, portability, and
public administration (7).
Health Canada is the national, federal health agency;
however, the operation of health service provision is
delegated to the provincial governments, which control
virtually 100% of Canadas hospitals. There is a
gatekeeper primary health care system. with GPs (general
practitioners) or primary care family doctors serving as the
entry point. Access to specialists, diagnostic testing,
hospitals, and others is through the GP. Individual citizens
have the freedom to choose their own doctors, 95% of
whom are self-employed in private practice. The
provincial government pays these doctors on a fee-forservice basis.
The individual provincial governments offer different
supplemental benefits not covered by the national
Medicare program, such as drugs, dental care, and vision
care to the poor, elderly, and other specific groups.
Supplemental benefits for the typical, employed, and
nonelderly person come from the purchase of supplemental health insurance from private sources (8).

Further controls exist at the provincial level at which

each province maintains a published formulary of drugs
that are reimbursable along with the reimbursement level.
Quebec, observers perceive, lists nearly all new drug
products, whereas Ontario appears to be slow to list newly
approved products. Each province has additional control
mechanisms. Ontario requires the first generic drug to be at
least 40% less costly than the branded originator product.
Some components of the reference price system are seen in
British Columbia and Newfoundland.
There is growing harmonization among the provinces;
however. there is still no national, standardized, and
interchangeable list of drugs for ambulatory care use. In
hospitals, drugs that are administered are paid for by
Medicare. Each province has interesting and different
features in its drug benefit plan.
The Prince Edward Island plan pays for seniors; welfare
recipients; nursing home patients; and those with
rheumatic fever, diabetes, tuberculosis, multiple sclerosis,
AIDS, and several other conditions. New Brunswick has
an annual copayment cap for seniors and for organ
transplant recipients and for selected other patient
categories. A copayment is set at approximately 59
(Canadian) but is waived for some groups in Quebec,
along with an annual copay ceiling of $750.
Other interesting features of the Canadian system
include its 1998 mutual recognition agreement with the
EU, prohibition of prescription drug advertising to
consumers, a 20-year patent exclusivity period, and the
establishment of the PMPRB to ensure fair pricing of
medications (9, 10).

Pharmaceuticals
Canada created the Patented Medicine Prices Review
Board (PMPRB) in 1987 to guarantee that pharmaceutical products would not have excessive prices in
Canada. The board reviews prescribed and over-thecounter (OTC) prices and publishes annual guidelines
for manufacturers. Compliance with PMPRB guidelines
is voluntary; however. since 1993, the board has
the authority to reduce excessive prices and return the
excess amount to the government, and to punish the
manufacturer.
The PMPRB compares prices in Canada with those in
seven industrialized nations (France. Germany, Italy,
Sweden, Switzerland, the United Kingdom, and the United
States) to ensure that Canadian prices are in line with those
of comparable countries. There is some controversy that
existing drug products are well-controlled regarding
prices, but that such is not the case with newly introduced
pharmaceuticals.

frica

Organization
The Republic of South Africa (RSA) has a most diverse
health care environment, with world-class practice and
facilities in wealthy urban areas and some of the most
primitive care in poor remote villages, with a vast array
between these extremes. Primary care is now the focus of
the ANC government in an effort to correct years of
neglect and undemocratic practices under the earlier
apartheid-oriented regimes. Public health services are
being brought to the Black townships as rapidly as
resources permit (1 1).
However, there are virtually no funds for new drugs
against HIV infection in patients. a problem most prevalent
in the RSA. To maximize the value of its drugs budget, the
RSA has enacted legislation to create an Essential Drugs
List for the public sector, along with generic substitution
authority, the removal of some pharmacists unique

Health Care Systems: Outside the United States

professional privileges, and legislation permitting the

parallel importation of pharmaceutical products already
registered in the RSA. Obviously, this conserves resources,
stretching them for more patients, but this angers the RSA
and multinational pharma firms.
South Africa is still the wealthiest country in Africa,
with a (1997) GDP at approximately $130 billion. It must
be noted, though, that aggregate numbers hide massive
racial differences. It is improving, but the standard of
living for Blacks is yet only slightly better than it is in
neighboring countries, whereas whites enjoy a standard of
living similar to that found in North America or Western
Europe. An unemployment rate of over 30% (mostly among
Blacks) exacerbates the fiscal situation (12).
Routine immunizations for children, conforming to the
World Health Organization (WHO) recommended schedule is the governmental policy, but it is not yet
accomplished in all regions. Infectious diseases including
HIV remain a serious challenge. Planning and budgeting
for resource allocation are difficult because accurate
census figures do not exist. Total health expenditures
appear to be in the area of $300 per person per year. and it
is estimated that the private sector accounts for greater
than 50% of total expenditures.
Public-sector expenditures emphasize primary care,
lately, at the expense of tertiary care facilities. Privatesector spending is primarily through private *medical
schemes. These are nonprofit organizations supported by
employer associations and employees. There are slightly
fewer than 200 of these schemes, providing insurance and
care payment for nearly 3 million workers and their 5
million dependents (of a total estimated RSA population of
40 million). The largest area of medical scheme
expenditure is for medicines, which causes the pressures
on pharmaceutical pricing addressed below. After drugs,
the next largest expenditures are for private hospitals,
medical specialists, general practitioners, and dentists (13).
The RSA Department of Health (DOH) has totally
restructured the previous apartheid system of racial and
provincial health systems into a coordinated national
health program operated through health regions and local
health districts. Still, there are major differences in
knowledge, education, expectations. and wealth within
different subpopulations (14, 15).

Pharmaceuticals
Until recently, manufacturers were free to establish their
desired price for a drug. Wholesalers and retailers added
what they chose to reach the retail selling price for
medications. In 1997, a proposed scheme of prices extending
to the retailer was agreed on, but resistance was met from the
Pharmaceutical Manufacturers Association(PMA). In the

391

legislation, a pricing board composed of members selected

by the Minister of Health would establish prices for each
product and a maximum selling price. Public-sector primary
care drugs are reimbursed 100% by the government.
Hospital care outpatient drugs can have copayments. The
Essential Drugs List would be the core of what is to be
available at public facilities, but there appears to be a long
way to go before most of these agents will be regularly
available on a consistent basis at primary care centers or at
public hospitals (13).
The parallel importation of RSA-registered drugs
available at lower prices abroad is the basis for PMA
litigation against the Drug Legislation of 1997. In addition
to the price-setting committee, DOH efforts to encourage
the use of generic drugs has proven to be a source of
conflict. Other features of the new legislation bar
dispensing samples or making bonus payments to
dispensers of medicines; the creation of a Code of Ethics
for pharmaceutical marketing; and a series of safety
regulations, dealing primarily with limiting practice to
fully qualified and licensed professionals.
There is a fast lane for new drug approvals if the
product is already in at least one of the following
jurisdictions: the United Kingdom, Canada, United States,
Sweden, or Australia. Approxmately 85% (by value) of
pharmaceuticals go through the nearly 3,000 community
pharmacies. Yet, approxmately 80% of the population rely
on the public sector for drugs, received through clinics,
hospitals, primary care posts. or military facilities.
Although there is a 20-year patent period of exclusivity1
protection, the parallel imports option effectively defeats
this protection.
It will be interesting to see how the access to drugs,
price controls, and quality improvement forces will
interact and what the actual situation will be in South
Africa in the coming years, especially as the country
complies with intellectual property and World Trade
Organization policies and rules (16).

Japan

Organization
After North America and before Western Europe, Japan is
the second largest pharmaceutical market in the world. Its
population of 126 million spends $70 billion on
pharmaceuticals each year. On average, each Japanese
resident spends $2000 each year on health care with $550
of that on pharmaceuticals. Perhaps the primary single
features of the Japanese market are the above-average
proportion of elderly in the population and the higher than
usual consumption of drugs. It has been estimated that by
the year 2050, nearly 30% of the population will be older

ealth Care Systems: Outside the United States

392

than 65 years of age. The high consumption rate is

attributed to drugs being injected and/or sold by the
physician, a practice used, in part, to increase the total
price of an office visit (17).
The primary funding source for health services in Japan
is the Social Insurance System (SIS), made up of employee
programs that pay for nearly 55% of care. The Medical
Service for the Aged program covers another 35% of care.
Private expenditures and a very small portion for public
health promotion and disease prevention make up the
difference. The Ministry of Health and Welfare (MHW)
maintains overall responsibility for health care services
and functions via a number of bureaus. Numerous sources
comment that regulations are difficult to understand and
interpret. often overlapping, and that this serves as a
barrier to foreign firms desiring to enter a market.
Physicians. for example, are authorized to own and operate
hospitals, effectively excluding corporate owners or
physicians not licensed in Japan (18).
Universal health insurance was established in 1961.
Nearly the entire population is covered through the
employer plans or through programs for the unemployed,
retired, or self-employed. Employees pay 10% of the cost
of treatments, up to an annual ceiling, and also pay a
portion of their premiums. with their employers.

Pharmaceuticals
The MHW sets prices for reimbursable drugs (those
approved for the Social Insurance System). Physicians,
clinics, and private hospitals are reimbursed at a price
slightly higher than their actual acquisition cost. The
government has scheduled annual reductions in the
reimbursement prices to reduce this source of additional
income to physicians. Patients make copayments of 20%,
although for children and low-income elderly the copayment is waived, and recently a plan to eliminate copayments
for persons 70 years of age and older was introduced.
The MHW reductions of 5 - 1 0 s of the prices of
existing drug products appear to have had the opposite of
the intended impact. Doctors are prescribing more of the
newest, high-priced pharmaceuticals that have not had
their margins reduced yet, thereby earning a bigger
amount from the wider difference between their actual cost
and the listed reimbursement amount.
With regard to generic drugs, astute observers believe
that the Japanese government wants its R&D-intensive
firms to be successful. A regulation requires generics to be
priced at not less than 40% of the innovator brand price. It
is reasonable to assume that the margins (Yakkasa) for
physicians are lower with generic drugs, and that these
margins will continue into the future, as will the reference
price scheme (19).

There is a Japanese pharmacopeia that sets official

standards and diverse government agencies that perform
tasks undertaken by an FDA. It is rumored that the Japanese
will establish a Western-style FDA in the near future.
One of the most disliked regulations in the view of
foreign and multinational pharmaceutical companies is the
requirement for duplicative clinical trials with humans in
Japan, because those carried out elsewhere are not
recognized. Also of interest is the fact that Japan, like
Korea and Taiwan, has no separation between prescriber
and dispenser of drugs. Called Bungyo, it is a major
source of revenue for doctors and clinics. Fewer than 20%
of prescriptions ever reach a pharmacy for dispensing (19).
Good post-marketing surveillance practices (GPiLISP)
rules have been in place since 1993. Postmarketing
experience reports are to be sent to a government agency.
Both GPMSP and periodic safety reporting requirements
are in place that require a review of the product each year
while it is in its re-examination period, immediately after
marketing approval. Unlike in the United States, where a
new drug application is approved for an indefinite period,
in Japan, there is a periodic full reassessment. Such
re-evaluations are conducted every 5 years once the
initial re-examination period for a drug product has ended.
Drug products are distributed primarily via the 2000
wholesalers, and in addition, there exists a small second
channel with drugs going directly to hospitals, GPs, and
pharmacies. There are approximately 66,000 pharmacies,
most of which are family-owned independents. There are
chains as well. However, a growing market for OTCs is
found in convenience stores.
Physicians administer and sell drugs to patients as a
highly profitable sideline. The incentive is for the
physician to use as much of the most costly drug products
as possible. There is only a small OTC market, because
physicians try to prescribe and dispense as much as is
possible. Other than some concern about a drug lag, the
pharmaceutical environment in Japan is robust. Periodically, there are calls to separate prescribing and
dispensing; however, this is not likely in the near future
given the powerful forces backing the status quo (20).

nite
Organization
With a population of more than 60 million and GDP per
capita of more than US $22,000, the United Kingdom is
one of the richest nations in the world. It is one of the G7
countries, a member of the European Union, and a member
of the Organization for Economic Co-operation and
Development (OECD).

Health Care Systems: Outside the United States

In 1996, total health care expenditure in the United

Kingdom was approximately 7.0% of the GDP. Public
expenditure by the National Health Service (NHS)
accounts for most of the health care costs. The NHS was
set up after World War 11, with the aim of unifying health
care services by voluntary and local hospitals. The NHS
offers free health services to all U.K. residents, funded
through general taxation.
Two of the major characteristics of the U.K. health care
system include health authorities responsible for hospital
services and GP fundholders responsible for primary care.
In 1996, 100 health authorities became operational in
England, responsible for the provision of NHS hospital and
community health services covering geographic boundaries with populations ranging from 125 thousand to over
1 million. There are four levels of hospital services. At the
community level, community hospitals offer basic medical
care for the treatment of acute cases and patients requiring
convalescent and long-termherminal care. General practitioners are the key staff here. At the district level, district
general hospitals operate the key acute units, serving an
average population of a quarter-million. At the regional
level, major specialty services such as neurosurgery,
open-heart surgery, and radiotherapy are provided. At the
national level, highly specialized hospitals provide
complex services for parts or for the entire country (21).
GPs are the gatekeepers and fundholders of the health
care system. The principle of fundholding is that GPs
manage their own budgets. They can obtain a defined
range of services from hospitals and manage patients at the
GP level whenever possible to reduce costs. In the late
1990s, GPs fundholders were organized into Primary Care
Groups (PCGs). These networks of GPs cover wide
geographic areas with an average population of 100,000.
In 1999, there were 481 PCGs in England and Wales, and
all have unified budgets (e.g., drugs, hospital care
services). With a population of a small to medium-sized
HMO in the United States, these PCGs have a very broad
influence on patient health care and the selection of drugs
through formularies.
Pharmaceuticals
The regulatory authority in the United Kingdom is the
Medicines Control Agency (MCA) under the Department
of Health. The agencys responsibilities include drug
licensing, clinical trials licensing, pharmacovigilance and
drug safety, communication and provision of information
on medicines, inspection of facilities and enforcement of
regulations, and the British Pharmacopoeia. The United
Kingdom is a reference member state for the European
Union mutual recognition procedure. The European
Unions pharmaceutical registration system came into

393

effect for all member countries in 1995. The aim of the EU

system is to harmonize pharmaceutical regulations
throughout the EU. The centralized registration procedure
is handled by the European Medicines Evaluation Agency
(EMEA). Authorization through the central registration
procedure is immediately valid in all EU member
countries. The decentralized procedure relies on the
principle of mutual recognition. After registration has been
obtained in a member country under the centralized
procedure, application may be made for registration in one
or more other member countries via the decentralized
procedure (21).
The majority of pharmaceuticals are distributed
through wholesalers to retail pharmacies, with large
pharmacy chains now dominating the market. There are
approximately 11,000 community pharmacies in the
United Kingdom (21). In recent years, pharmacy services
are increasingly available in supermarkets at the expense
of local independent pharmacies.
Total expenditure on pharmaceuticals in the United
Kingdom amounted to approximately 8650 million pounds
in 1999. accounting for approximately 17% of the total
health expenditure (2 1). The NHS covers prescription
drugs. However, the government does not reimburse for
over-the-counter (OTC) products. The Department of
Health indirectly controls pharmaceutical prices. Because
the price control scheme is related to profit control, rather
than to the prices of individual products, pharmaceuticals
are relatively free-priced in the United Kingdom. The
government operates a negative list for products that are
not reimbursable. The cost of most licensed prescription
products is fully reimbursed. However, cost constraints and
prescribing budgets mean that GPs will often prescribe a
generic when one is available. As a result, new prescription
drugs usually have a slower penetration rate in the United
Kingdom than in the United States. The recently
introduced National Institute for Clinical Excellence
(NICE) will add more barriers to the introduction of new
pharmaceutical products in the United Kingdom.
National Institute for Clinical Excellence
Funded by the government, the National Institute for
Clinical Excellence (NICE) was set up as a Special Health
Authority in the United Kingdom in 1999 and, as such, it is
a part of the National Health Service (NHS). It was set up
to provide the NHS [patients, health professionals, and
the public] with authoritative, robust and reliable guidance
on current best practice. Its key functions are to appraise
the clinical benefits and the costs of those [health care]
interventions and to make recommendations. Guidance is
issued from each appraisal based on the clinical benefits,
cost-effectiveness, and total economic impact on the

394

National Health Service. The government does not have to

adhere to the recommendations by the NICE in its
guidance and financial payment to health care providers.
However, many believe that a negative recommendation
from the NICE will have a detrimental impact on the
pricing, reimbursement, and sales of the appraised product
not only in the United Kingdom but also throughout
Europe, Australia, and Canada.
The guidance covers both individual health technologies (including medicines, medical devices, diagnostic
techniques, procedures, and health promotion) and the
clinical management of specific conditions. The Institute
may recommend a technology for general use, for specific
indications, or for defined subgroups of patients. Based on
the appraisal, a therapeutic intervention (e.g., drug) will be
classified into one of three categories: category A, routine
use in the NHS: category B, further trials needed; and
category C, not recommended for routine use in the NHS.
The NICE has a board reflecting a range of expertise
including the clinical professions, patients and user
groups, NHS managers, and research bodies. The Board
ensures that the NICE conducts its business on behalf of
the NHS in the most effective manner. Details of the
appraisal process and membership of the Appraisals
Committee are available on the NICE Web site
(www.nice.org.uk). Because the NICE was new at the
time of completion of this article, its impact on the
pharmaceutical industry is still not clear.

~ ~ r n ~ n ~
Organization
With a population of approximately 82 million in 1998 and
a GDP per capita of more than $26,000, Germany is one of
the worlds largest economies and health care markets.
The population enjoys a generally good standard of health
with a high degree of public awareness about healthrelated issues. Life expectancy in Germany is among the
highest in the world. In 1997, the life expectancy for males
was 74 years and for females 80. Approximately 15.8% of
the population were over 65 years in 1997, and it has been
projected that by 2020, the number of German inhabitants
aged over 60 years will be 28.2% (22).
In 1997, health expenditures in Germany totaled $298
billion, equal to 14.2% of the GDP. The health care system
in Germany is decentralized, and health care expenditures
are covered by a variety of sources/payers. The statutory
insurance system (GKV) represents the biggest proportion
of the total care coverage (for almost 50%). Employers,
government budget, private households, private insurance,
retirement insurance, and accident insurance cover the

Health Care Systems: Outside the United States

remaining 50% of the health care expenditures. The largest

spending sector is hospital expenditure, representing
34.3% of the total GKV health care expenditures (22).
The federal government has little executive responsibility for the provision of health care in Germany. Its
primary responsibility is to provide a regulatory framework within which the individual Lander have to operate.
The health ministries of the individual Lander are
responsible for implementing the federal legislation,
enacting their own legislation, supervising subordinate
authorities and the medical profession, hospital planning,
and regional administration.
Hospitals in Germany can be classified into three major
categories based on ownership: public, nonprofit, and
private. In 1997, the public sector operated approximately
40% of general hospitals, and nonprofit organizations
operated another 40%. However, the number of privately
owned facilities has been increasing steadily over the past
decade.
The number of practicing doctors has risen steadily for
thepast 1Oyears.More than70% ofthepracticingdoctors are
specialists, with general medicine as the largest specialty.
Fewer than 30% of doctors practice without any specialty.

Pharmaceuticals
Germany is a reference member of the EU pharmaceutical
registration system. The European Medicines Evaluation
Agency (EMEA) handles the centralized registration and
the decentralized registration procedures in individual
countries. After marketing authorization of a product with
a new active substance has been granted in one country,
the mutual recognition procedure is compulsory in other
member countries. The mutual recognition procedure is
also compulsory for line extensions and generic products.
Marketing authorization approvals in Germany are valid
for 5 years and renewable thereafter in 5 year periods.
Germany is the home of some major multinational
pharmaceutical companies such as Aventis, BASF, Bayer,
Boehringer Ingelheim, Merck KGaA, and Schering AG.
VFA is the research-based manufacturers association,
whereas the Bundesverband de Pharmazeutischen Industrie
(BPI) represents small and medium-sized companies.
Because North America is the largest pharmaceutical market in the world. many of the VFA pharmaceutical companies locate their key operations in the United States. Exports
to Western European countries represent a major source of
income for many of the German pharmaceutical companies.
The pharmaceutical market in Germany is one of the
largest in the world. Based on drug use per capita, Germany
is second only to Japan in the consumption of pharmaceuticals. The principal distribution channels for pharmaceuticals in Germany are public retail pharmacies and hospital

Health Care Systems: Outside the United States

pharmacies. In 1998, there were 47,322 pharmacists in

Germany, equal to 0.6 pharmacists per thousand population
(22). Public (retail) pharmacies employed 96% of all
pharmacists in 1998 and they obtained their supplies
primarily from wholesalers. Prescribed drugs. including
both branded and generic products, can only be dispensed in
a pharmacy with a doctors prescription. The generics
market in Germany is one of largest and fastest-growing in
Western Europe, representing approximately one-third of
the European generics markets. OTC products can be
divided into three overlapping categories: prescription
OTC medicines, nonprescription OTC medicines, and
freely available QTC products that can be sold freely
through all retail outlets such as health food stores,
supermarkets, and other retail outlets.

exic
Organization
Mexico is a federal republic of 31 states and a federal
district. The population was officially estimated to be 97.7
million in 1997. GDP per capita was estimated at
approximately US $4400 in 1998. As a developing nation,
communicable diseases are still one of the major causes of
mortality, although chronic and degenerative diseases have
become the leading cause of death during the past decade.
One of the major challenges for the government is to
address the inadequacies of the Mexican health care system.
Approximately 10 million people have virtually no access
to regular basic health care services, and another 20 million
people have less than adequate access. In 1996, the total
health care expenditure in Mexico was equivalent to
approximately 4.6% of GDP. Spending by the public sector
accounted for approximately 60% in 1996 (23).
There are three sectors in the Mexican health care
system: public, social security, and private. The public
sector is primarily directed and operated by the Secretariat
of Health. The public sector of health services is under the
Secretariat of Health and is coordinated by over 200 health
districts. The Federal District Department provides health
care services to some 3.2 million people in Mexico City.
The Mexican Social Security Institute (IMSS) Solidarity
program covers another 10 million people in rural areas.
The social security system covers health services for
government employees, managed by the Social Insurance
Institute of State Employees (ISSSTE), and for privatesector workers, managed by the Mexican Social Security
Institute (IMSS). The two agencies operate their own
networks of hospitals and clinics and provide similar
benefits. Some other smaller social security agencies exist,
providing medical services for special groups such as the
army, navy, and state oil company personnel.

395

The private (commercial) sector includes private

hospitals, doctors offices, and practitioners of traditional
medicine. Charity organizations such as the Red Cross also
play a role in the Mexican health care system.
Pharmaceuticals
The regulatory authority in Mexico is the Direcci6n
General de Control de Insumos para la Salud (DIGECIS).
The Health Secretariat issues pharmaceutical registration.
Safety and efficacy must be proven by phase I11 clinical
trials in Mexico to register drugs that are new to the
Mexican market. All major pharmacopeia (International
Pharmacopoeia, US Plzarinacopeia, British Pharmacopoeia, French Pharmacopoeia, Swiss Pharmacopoeia,
European Pharmacopoeia, and Japanese Pharmacopoeia)
are acceptable in Mexico.
Most domestic producers in Mexico are wholly owned
or licensed subsidiaries of multinational pharmaceutical
firms. Exports have been growing fast, with other Latin
American countries as the major destination markets.
However, the United States is the major supplier of
pharmaceutical imports in Mexico.
Pharmaceuticals in Mexico are subject to government
price control. The private sector accounts for approximately 85% of the pharmaceutical market. Prescription
dmgs account for the majority of the pharmaceutical
market, with antibiotics as one of the largest classes.
Because the use of generics is still a relatively new
phenomenon, most of the prescribed pharmaceuticals are
branded products. OTC products represent approximately
one-fifth of the total pharmaceuticals market.

su
As presented, these six representative countries use vastly
different organizations, financing mechanisms, goals, and
provision structures. In fact, few systems around the world
are identical because the systems represent the values and
priorities and political as well as economic leanings and
traditions of that country. If there were one perfect system,
we would be seeing migration toward that model.
However, because this is not the case, it is reasonable to
assume that most of the various systems encountered
around the world are at least satisfactory in their
foundations and macrolevel characteristics, even if some
of the operating details are not always popular (24).
The world is full of interesting additional approaches
that a serious student of this subject might wish to explore
further. Some of these include the -need clause used in
Norway, where, for example, their FDA had the authority

396

to refuse to accept and review a new drug because Norway

already had six benzodiazepines on the market. The FDA
deemed that sufficient unless the sponsoring company
knew of a new indication or other therapeutic breakthrough from its use. The Swedes bought all of the thenexisting community pharmacies in the country in 1970 to
rationalize distribution, and service level and to create a
monopsonistic body for negotiating with manufacturers in
price-setting. The French and others place new drugs into
one of several reimbursement categories. Clearly, lifesaving drugs are put in the 100% reimbursement (to the
patient) category. Most others strive for the 70%
reimbursement category; however, if the manufacturer
cannot agree on a price satisfactory to the Social Security
agency, the product will be placed in a lower reimbursement category, effectively hampering its market success.
This is a powerful bargaining chip for the government to
contain drug prices.
It will be interesting to watch the future in this area to
see how medications previously requiring a doctors
prescription that move to OTC status are handled, and how
nutraceuticals, herbals. homeopathic, and naturopathic
drugs, without the benefit of rigorous, randomized clinical
trial or outcome data are handled as well. Similarly, we
can be certain that there will be excitement galore when
the nations in Central America and the Middle East decide
to control pharmaceuticals and to end the practice of layperson purchases of virtually any product without the
benefit of a physicians order. Separation of pharmacy and
physician functions will occur in the Far East in the not too
distant future, causing even more excitement or grief.
If logic dictates, we should expect to see in the future a
trend to offer incentives for prescribers who use the most
cost-beneficial products (bonuses) and disincentives for
patients (reimbursement level co-payment differences)
and physicians when less than optimal choices are made.
Irrespective of whatever does actually occur, it will be
most interesting to observe.

1. Roemer, M.I. National Health Systems of the World;

Oxford University Press: Oxford. UK. 1993: 2, 61.
2. Fry, J.; Farndale, W.A.J. International Medical Care;
Washington Square East: Wallingford, PA, 1972; 367.
3. In OECD Health Systeins: Facts and Trends; OECD: Paris,
1993; 100-161.
4. Hewitt. M. International Health Statistics; Office of
Technology Assessment, U.S. Congress: Washington,
D.C.; 1993: 76-86.
5 . Elling, R.H. International Health Perspectives; Springer:
New York, 1977; 4, 17-25.

Health Care Systems: Outside the United States

6. Joseph, S.C.; Koch-Weser, D.; Wallace, N. Worldwide

Oveiview of Health and Disease; Springer: New York,
1977; 7-43.
7. Korman, R.A. Academic Reference Manual: Canadian
Health Care Information; IMS Health: Mississauga,
Ontario, 1999; 80-162.
8. World Pharmaceutical Markets: Canada; Espicom
Business Intelligence: Chichester, UK, May, 1999; 9-48.
9. Alleyne, G.A.O. Health Statistics from the Americas; Pan
American Health Organization: Washington, DC. 1998;
17-37.
10. Alleyne, G.A.O. Health in the Americas: Pan American
Health Organization: Washington, DC, 1998; 1, 325-337.
11. Monekosso. G.L. Eighth Report on the World Health
Situation; African Region; WHO: Brazzaville, 1994; 2,
2-37.
12. Nokagima, H. Eighth Report on the World Health
Situation; 147-165 Global View: Geneva, 1993; I , 37-59.
13. World Pharmaceutical Markets: South Africa: Espicom
Business Intelligence: Chichester, UK, Feb 1999; 3- 13.
14. World Development Report 1993, World Bank;
Jamison, D.T., Ed.; 108- 170 Oxford University Press:
Oxford, 1993; 3-65.
15. World Tables 1995; World Bank: Washington, DC, 1995;
22-66.
16. Basch, P.F. Textbook of International Health; Oxford: New
York, 1990: 144-326.
17. Bartholomews Mini World Factfile; Harper Collins:
London, 1995; 44. 102, 175.
18. Eighth Report on the World Health Situation: Western
Pacijic Region; World Health Organization: Manila, 1993;
I,79-83.
19. World Pharnzaceutical Markets: Japan; Espicom Business
Intelligence: Chichester. UK, Jan 1999; 10-23.
20. SCRIP: London UK, 1998, 1999, and 2000.
21. World Pharmaceutical Markets: United Kingdom; Espicom
Business Intelligence: Chichester, UK; Feb 1999; 17-70.
22. World Pharmaceutical Markets: Germany; Espicom
Business Intelligence: Chichester. UK, Feb 1999.
23. World Pharmaceutical Markets: Mexico; Espicom
Business Intelligence: Chichester, UK, Feb 1999.
24. Brudon, P. The World Drug Situation; WHO: Geneva,
1988; 7-108.

Alexander, T.J. Internal Markets in the Making: Health Systems

in Canada, Iceland, and the UK,OECDF: Paris, 1995.
Saltman. R.B.; Figueras, J.; Sakellarides. C. Critical Challenges
for Health Care Reform in Europe; Open University Press:
Buckingham, UK, 1999.
Schneider, M.; Dennerien, R.K.: Kose, A.; Scholtes, L. Health
Care in the EC Member States; Elsevier: Amsterdam. 1992.
Spivey, R.N.: Wertheimer, A.I.; Rucker, T.D. International
Pharmaceutical Services; Haworth: Binghamton, NY, 1992.
The Use of Essential Drugs: 6th Report of the WHO Expert
Committee; WHO: Geneva, 1995.
Van de Water, H.; Van Herten, L.M. Health Policies on Target;
THO Prevention and Health: Leiden, 1998.

PHARMACY PRACTICE ISSUES

s:
American Society of Health-System Pharmacists, Bethesda, Maryland, U.S.A.

A national health care system reflects the social, political,

economic, and cultural character of a nation. k nations
historical roots and dominant values shape policies and
directions for the organization, quality, financing, and
access to health care services. These factors determine
who gets what kind of care-at which locations, for what
price, and paid by whom.
The distinctive historical antecedents of American
cultural and social development have shaped the present
health care system. These contexts have led to a health
care system that is uniquely American in character and
composition. Although the issues currently facing the
American health care system bear some similarity to those
in other developed, industrialized nations, many of the
factors are unique to the United States.
Social values, that is, the collective societal beliefs
about the nature of the human being and the structure of a
society, play a strong role in the development of national
policies. Political and economic decisions rest in large
measure on the prevailing values held in a society. Hence,
if a predominant social value rests on the notion that all
societal members have a right to health care, political and
economic policy developments will follow suit. One way
of examining these contexts is to look at a spectrum of
social values.
Donabedian (1) has proposed that such a spectrum
might be considered from two polar positions: libertarianism versus egalitarianism. Dougherty (2) adds the
dimensions of utilitarianism and contractarianism. The
essence of these taxonomies of social values is that they
characterize specific sets of beliefs and values held by a
wide array of individuals.
Libertarian philosophical thought places major emphasis on personal achievement and freedom from political
intervention. It holds that individuals should be free to
exert their rational capacity to evaluate and determine
what is good for them. They can then further act on these
determinations for themselves from their own personal,
fiscal, physical, and human resources. To this view,
Dougherty (2) adds:
Encyclopedia of Clinical Pharmacy
DOI: 10.1081E-ECP 120006170
Copyright 0 2003 by Marcel Dekker, Inc. All rights reserved

Because they can think. persons can understand their

circumstances and the alternatives available to them.
Because they can choose, persons can act to affirm
or change their circumstances. Because they can
think and choose, persons are free to create their own
life plans and the values of which they are made.

It follows then, that predominant libertarian values are

deeply entrenched in the notion of the self-made person
and that social rewards should only accrue if they are
deserved and earned. The role of government is, therefore,
limited to those functions that absolutely do not abridge
the rights of the individual to exert his or her own will for
what he or she believes to be best. Moreover, governments role would be limited to those functions and needs
for which individuals could not provide (national defense,
negotiation of treaties, etc.).
Egalitarian principles focus on the equal moral standing
of all individuals regardless of achievement or station in
life. This philosophy also centers on the right to equal
opportunity and to the extent possible, to be free from need
and want. Thus, egalitarianism (2) can be viewed as
follows:
Practically, this means an equal right to a reasonable
share of those basic goods and services known to be
necessary for a decent human life, including a right
to a job, minimum income support, or provision in
kind of the goods necessary for life, as well as a right
to a range of social and health care services designed
to prevent and minimize psychological and physical
suffering, disabilities. and premature death.

Egalitarian values place specific demands on government and political policy to construct broad services and
support systems so that all members of society are
provided with equal opportunity designed to prevent and
minimize psychological and physical suffering and
disabilities, and to achieve ones lifes aims. In this
fashion, government would act on the entitlements due to
all members of society. Such entitlements might be
derived from legal or other forms of social consensus.
This range of social values from libertarianism to
egalitarianism holds differing beliefs about equality,
397

398

justice, opportunity, rights, and the functional

responsibilities of government. When this spectrum of
social values is held over health, health care, and the
administration and financing of health care services, it is
not surprising that a vastly different array of designs
emerge. Because health and health care are so tightly
wound into personal, cultural, and social beliefs, it is not
surprising that such a vast array of health care systems and
notions about health have emerged across the world.
Americas historical foundations have leaned strongly
to the libertarian philosophical viewpoint (3). The
influence of the Protestant ethic from Europe, coupled
with the opportunities that a fresh land provided to
become ones own person, are strongly borne out in
American society. An unbridled, free-market economy
and freedom from governmental intervention in the daily
lives of the citizenry are strong values that have been
integrated into the American lifestyle and American
political economic thought. The notion of pulling
yourself up by your bootstraps succinctly reflects these
dominant social, political, and economic values. Such
antecedents are reliable markers for characterizing
Americas health care system. Consequently, it is a
fascinating mosaic of pluralistic approaches. It is a
strongly market-driven, industrialized system, which, at
the same time. may be described as one of the worlds best
and one of the worlds most troubled systems.
The United States does not have a universal health
insurance program characteristic of many developed
nations. Nor does it have national health care services
like that of the United Kingdom and other nations. Except
for those persons in the United States who possess special
legal entitlements. the American health care system is
largely a private enterprise; in other words, an industrialized system. The providers, payers, and institutions of
care represent a rich mixture of private agents,
corporations, insurance systems, and governmental
agencies. There is not a singular rationalizing source for
setting broad-based national policy and direction for the
health care system as a whole. Rather, the vast market
place of ideas has a variety of options in order to
implement any proposal for which someone will pay.
Relman has termed this approach the industrialization of
health care (4).
The role of the national and state governments in the
health care system is limited to those entitlement programs
that have been legislated into federal or state law or where
there is a federal and state partnership. Federal involvement in the provision of health care services began with
the U S . Public Health Service (PHS), an agency of the
U S . government. The PHS was established in 1798 to
provide essential health care services to merchant marine

Health Care Systems: Within the United States

personnel and members of the U.S. armed forces.

Subsequent federal involvement in the provision of and
the payment for health care has incrementally increased to
include care for individuals with special entitlements. The
latter include veterans of the armed forces, the elderly,
indigent people, Native Americans, persons with
HIV/AIDS, certain disabled individuals, and qualifying
persons with end-stage renal disease. For example,
qualified veterans of the armed forces have access to a
federal system of hospitals, clinics, and long-term care
facilities under the Department of Veterans Affairs (a
cabinet-level agency of the executive branch of the federal
government). Since 1965, the federal government sponsors
Medicare. a health insurance program for the elderly
(65 years of age and over and later the disabled). The
federal government also cost-shares with participating
state governments to provide the Medicaid program (also
enacted in 1965). The latter is an insurance program for
health services directed toward qualifying indigent people.
In Medicare and Medicaid, institutional and individual
providers participate as contractors under a set of specific
conditions for participation.
State and local (city and county) governments have
limited roles in the provision of health care services. State,
county, and city health departments are as differently
organized and functioning, as there are states, counties,
and cities in the United States. These agencies reflect and
represent the special needs of the geographic areas and
demographic compositions of their respective domains.
Hence, the functioning and expanse of services offered by
the New York City Department of Health is vastly
different from a similar agency in rural Montana.
This unique approach to the application of a health care
system must also be examined in light of the diversity of
the demography and geography of the United States.
Approximately 273 million people inhabit the United
States across a geographic expanse of 3.5 million square
miles of land. Ranging from the deserts of Nevada to the
Rocky Mountains of Colorado and Wyoming to the tropics
of Florida and the oceanic seaboards of the east, west, and
southern coasts, American geography and topography is
expansive (5). Hence, a substantial challenge to the
delivery of health care services exists in this array of
geographical areas.
The American population is equally diverse and
expansive. There are almost 35 million people who are
age 65 or older. African Americans constitute 12.8% of the
population, Asian and Pacific Islanders 4%, American
Indians 0.9%, and Caucasians make up 82% of the
population (5). Because the United States is largely a
nation of immigrants, there are literally hundreds of
additional ethnic groups that are part of the American

Health Care Systems: Within the Cnited States

social fabric. As of March 1997. 25.8 million individuals

in the United States were foreign-born, which represents a
30% increase from 1990, when there were 19.8 million
foreign-born individuals in the United States. Mexico was
the place of origin for 7 million or 28% of the total foreign
born population in 1997 (5). During 1996 and 1997. 1.3
million people moved to the United States from abroad,
and 92% of those individuals moved to metropolitan areas.
Additionally, during this time period, 3 million people left
the central cities and 2.8 million moved to the suburbs (6).
The health care system of the United States should then be
viewed in the following context:

A diverse spectrum of social values. which have

historically pointed more toward libertarianism than
egalitarianism
Limited roles of the federal, state, and local governments in the provision of, and payment for, health care
services
A pluralistic, free-market approach to the provision of
health care services
A geographically diverse and substantive land mass
A culturally diverse and numerically large population
whose characteristics are changing toward more elderly
and racial and ethnic heterogeneity

It is critical that the reader be sensitive to these

contextual variables to understand the American health
care system and how health care policy is shaped and
implemented in the United States.

Health care services in the United States are provided by a

broad array of facilities, which are financed from a variety
of payment sources. As of 1998, there were 6021 hospitals
(7), 1,012,582 hospital beds, 33,765,940 admissions, and
241,574,380 inpatient days. In 1998, the average length of
stay in community hospitals was 6 days, whereas it was 7.7
days in 1975 (7).
It is also notable that the numbers ofhospitals in urban and
rural settings are shrinking. In 1993, there were 3012 urban
hospitals and 2249 rural. whereas in 1998, there were 2816
urban and 2199 rural hospitals (13). The numbers of public
acute care hospitals decreased from 1390 in 1993 to 1260 in
1997 (8). Closure of hospitals and simultaneous reductions
in hospital beds has occurred in inner city areas where care is
provided for large numbers of indigent patients. Such
closures are related to the high costs of care. which are not
concomitantly reimbursed by state and federal sources

399

either because the individuals are not eligible or because

uavment rates do not cover the costs incurred. Small.
isolated rural hospitals are facing similar economic and,
hence, survival difficulties. The plight of rural hospitals is
of special significance because their survival is often linked
to the economic and social survival of a rural community.
While the worlds population grows at an annual rate of
1.796, the population over 65 increases by 2.5% per year.
There are just fewer than 600 million people over the age
of 60 in the world. Approximately 360 million of the
worlds over 60 population lives in the developing world,
in which 7.5% of the population is elderly. In contrast,
18.3% of the population is elderly in the developed world.
The most rapid changes are occurring in some developing
countries where an increase of 200-400% in the elderly
population is predicted over the next 30 years (9). Because
of the growth of the elderly population, there has been an
increase in the demand for geriatric and long-term care
facilities. Over the next several decades, the elderlys
health care consumption in the United States will be
approximately $25,000 per person (in 1995 dollars)
compared to $9200 in 1995 (10). In this respect, the United
States is following the trends exhibited in most developed
industrialized countries.
The increased utilization of health care services by the
elderly is expected to put additional strains on an already
besieged health care system. Increasing the life span, either
through preventive measures or through other acts of
distributive justice, solves some problems while creating
others. This astounding paradox will assuredly complicate
the political and social processes of decision making.
Equally likely will be the burdens these phenomena add to
an already overburdened national economy.
In the last several years, it is the substitutability that
has been emphasized, as more and more procedures are
performed in outpatient settings. Many services previously performed in the hospital now take place in
physician offices. In 1996. there were 734,493,000 visits
to the physician, with an average of 3.4 per person (1 l),
and the most frequent principal reason for a visit was a
general medical examination, with a total of 54.7 million
in 1996. Also in 1996, there were 67.2 million visits to
outpatient departments, and 40.3 million inpatient
surgery procedures were performed (1 1). This analysis
points to the increasing importance of the ambulatory
care setting as a place for rendering care. The relevance
of outpatient care will continue to grow as more medical
procedures are performed outside hospitals and greater
emphasis is placed on preventive care. Outpatient visits
in community hospitals alone have advanced from
263,631,000 in 1986 to 301,329,000 in 1990 to
474,193,000 in 1998 (7).
l

Health Care Systems: Within the United States

400

The National Association of Home Care estimates that

more than 20,000 providers deliver home care services to
approximately 8 million individuals each year (12).
According to the Health Care Financing Administration
(HCFA), the average number of home health visits a year
per Medicaid beneficiary was 80, compared to 21 visits in
1989. Additionally, the number of home health agencies
participating in Medicare has increased from almost 5000
in 1988 to over 10,000 in 1997 (13). Care of patients in
home settings is likely to expand as data further suggest
reduced cost for such care without compromising quality.
Technological and scientific developments related to
providing sophisticated treatments in the home will also
stimulate growth in this sector of health services.

LT

RAG

According to the Presidents Advisory Commission on

Consumer Protection and Quality in the Health Care
Industry, there are five trends that summarize the
characteristics of health insurance plans of the late 1990s:
Increased complexity and concentration of health plans
Increased diversity of health insurance products
Increased focus on network-based delivery
Shifting financial structures and incentives between
purchasers, health plans, and providers
The development of clinical infrastructure for utilization management and quality improvement (14)
In response to rapidly increasing health care costs,
private insurance companies and employers (who pay the
premiums in whole or in part for their employees) have
increased their part in implementing cost-containment
strategies. A dramatic effort has been the application of
business principles to purchasing and vendor selection and
payment for and selection of health care providers and
institutions of care.
Private employers, the federal government, and state
and local governments invest significant financial
rescturces in health care purchasing expenditures. In
1995, private employers contributed S183.8 billion to
private health insurance premiums, whereas the federal
government spent $1 1.3 billion on private health insurance
premiums, and state and local government spent S47.1
billion (14). In 1995, more than 83% of the insured
population was covered by private insurance, whereas
about 31% was enrolled in a public program, such as
Medicare or Medicaid.
Probably the most significant change in the
American health care system in recent years is the

development of managed care. In managed care

settings, the covering company is responsible for
providing services, whereas, at the same time, it is
exposed to the financial risks of unanticipated services.
Health Maintenance Organizations (HMOs) contract
with hospitals and certain physician providers for
services within a negotiated schedule of fees. HMOs
and other such managed care organizations specify
where and by whom care is to be given. The latter is a
radical departure from the historically preeminent
freedom of choice that patients and care providers
enjoyed under the traditional indemnity and fee-forservice reimbursement programs. The traditional method
of paying for medical services is fee-for-service when
the provider charges a fee for each service provided,
and the insurer pays all or part of that fee.
Managed care is an umbrella term for HMOs and all
health plans that provide health care in return for preset
monthly payments and coordinate care in a defined
network of primary care physicians and hospitals. A
network includes physicians, clinics, health centers,
medical group practices, hospitals, and other providers
that a health plan selects and contracts with to care for its
members. An HMO is an organization that provides health
care in return for preset monthly payments. Most HMOs
provide care through a network of physicians, hospitals,
and other medical professionals that their members must
use in order to be covered for that care.
There are a number of different types of HMOs. A
staff model HMO is an HMO in which the physicians
and other medical professionals are salaried employees,
and the clinics or health centers in which they practice
are owned by the HMO. A group model HMO is made
up of one or more physician group practices that are not
owned by the HMO but operate as independent
partnerships or professional corporations. The HMO
pays the groups at a negotiated rate, and each group is
responsible for paying its doctors and other staff as well
as covering the cost of hospital care or care from outside
specialists. An Independent Practice Association (IPA)
generally includes large numbers of individual private
practice physicians who are paid either a fee or a fixed
amount per patient to take care of the IPAs members. A
Preferred Provider Organization is a network of doctors
and hospitals that provides care at a lower cost than
through traditional insurance. PPO members have more
health coverage when they use the PPO s network and
pay higher out-of-pocket costs when they receive care
outside the PPO network (15).
An integrated health system is a network that provides a
coordinated continuum of services and is clinically and
fiscally accountable for outcomes. There was a significant

401

Health Care Systems: Within the United States

growth of integrated health systems during the late 1990s.

In 1997, there were 228 integrated systems and, in 1998,
there were 266, representing an increase of almost 17%
(16). Simultaneously, there has been a disintegration of
systems when mergers fail and disassemble. Iglehart
comments on how managed care has changed the face of
health care:
Before the emergence of managed care, it was
largely physicians, acting individually on behalf of
their patients, who decided how most health care
dollars were spent. They billed for their services, and
third-party insurers usually reimbursed them without
asking any questions, because the ultimate payersemployers-demanded no greater accounting. Now,
many employers have changed from passive payers
to aggressive purchasers and are exerting more
influence on payment rates, on where patients are
cared for, and on the content of care. Through
selective contracting with physicians, stringent
review of the use of services, practice protocols,
and payment on a fixed, per capita basis, managedcare plans have pressured doctors to furnish fewer
services and to improve the coordination and
management of care, thereby altering the way in
which many physicians treat patients. In striving to
balance the conflicts that arise in caring for patients
within these constraints, physicians have become
double agents. The ideological tie that long linked
many physicians and private executives-a belief in
capitalism and free enterprise-has been weakened
by the aggressive intervention of business into the
practice of medicine through managed care (17).
There has been a recent challenge to the core tenet of
managed care that centralized decision making could
deliver improved care at a reduced cost. In November
1999, a large health care company decided to allow
physicians to choose what care patients need without the
insurance companys intervention or approval. This
action opens the door to further discussions about how
managed care principles are utilized. Regardless of
managed cares future course, cost containment measures
will be necessary to prevent an explosion of health care
costs. The demand for cost containment will need to be
weighed against the imperative to insure that patients
have access to care. Paul Ellwood, often referred to as the
father of the HMO, believes that there will be a new era
in which patients, not employers and government
purchasers, will have power (18). Regardless, the weight
of political and consumer pressures, along with
experience and economic efficiency, will determine the
future of managed care.

LTH c

61

The expenditures for health care in the United States have

grown from $51 billion in 1967 (6.3% of GNP) to over $1
trillion in 1997 (14% of GDP). In 1997, on a per capita
basis, $4090 was spent on health care (19) and 0.64 per
daylcapita was spent on prescription drugs (20). This is
substantially higher than that of other industrialized
nations. When comparing health expenditures in the major
industrialized countries comprising the Organization for
Economic Cooperation and Development (OECD), for
example, dramatic differences in per capita expenditures
are noted (21). Such differences also exist in the
percentage share of GDP spent on health care (21). and
relative growth in health care expenditures over time
varies greatly among these countries (21, 22).
The Health Care Finance Administration asserts that
national health expenditures are projected to total $2.2
trillion and reach 16.2% of the GDP by 2008. The growth in
health spending is projected to average 1.8 percentage
points above the growth rate of the GDP for 1998-2008.
This differential is higher than recent experience but
remains below the historical average for 1960- 1997, where
growth in health spending exceeded growth in GDP by close
to three percentage points. There are a number of factors
that contribute to the projected acceleration, including:
An increase in private health insurance underwriting
cycle
o A slower growth in managed care enrollment
o A movement towards less restrictive forms of managed
care
A continued trend toward increased state and federal
regulation of health plans
The growth of health case expenditures without a
concomitant gain in health status of the population is
receiving more and more attention on the governmental
and corporate agenda. On the governmental level, an
increasing proportion of federal and state budgets is being
allocated to health care. In the private sector, corporations
and individuals are bearing larger proportions of health
care costs. Although no particular percentage of GDP has
been determined to be an acceptable or unacceptable
expenditure for health care services, the fact is that costs
are increasing and the health care sector is gaining an
increasing share of the economy. This follows several
other interesting trends. During the period of 1961 to 1997,
The GNP is the total annual flow of goods and services in a nations
economy. Most industrial countries now use GDP, which measures the
value of all goods and services produced within a nation, regardless of the
nationality of the procedure.

402

national health expenditures as a percentage of GNP rose

from 5.4% to over 14%. In the same period, dramatic
differences occurred in the source of revenues for health
care expenditures. The pattern of spending these resources
also changed significantly (13).
In 1960,49% of health care revenues came from out-ofpocket payments from individuals. Out-of-pocket spending is defined as expenditures for coinsurance and
deductibles required by insurers, as well as direct
payments for services, which are covered by a third
party. In 1990, individual consumers spent S144.4 billion
directly for out-of-pocket payments for personal health
services (23). This accounted for 38% of all personal
health spending. In 1998. consumers spent S183.7 billion
in out-of-pocket payments, which accounts for 33% of the
$558.7 billion in personal health spending (23).
Consumers have spent and continue to spend less of
their own personal money for health care services. This
decrease in personal spending has been shifted largely to
third parties, such as private health insurance, government
programs. philanthropic organizations, and other sources.
It is evident that the shift away from personal, out-ofpocket health spending has resulted in greater consumption
of health care services. This transition reflects the general
maxim in health care economics that the consumption of
health care services is probably insatiable (24). Moreover,
unlike other sectors of the economy and the laws of
economics they obey, prices for health care services do not
fall with increased consumption or purchasing.
According to Iglehart. the decline in personal spending
is attributed in large part to the growth in health
maintenance organizations (HMOs), which traditionally
offer broad benefits with only modest out-of-pocket
payments. In the past few years, however, most HMO
enrollees have had increased cost-sharing requirements, as
employers and health plan managers have sought to
constrain spending even further. Out-of-pocket payments
are still considerably less in an HMO than with indemnity
insurance (17): However, The overall declines in per
capita out-of-pocket spending mask the financial difficulties of many poor people and families. A recent study
estimated that Medicare beneficiaries over 65 years of age
with incomes below the federal poverty level (in 1997 the
level was $7755 for individuals and $9780 for couples)
who were also eligible for Medicaid assistance still spent
35% of their incomes on out-of-pocket health care costs.
Medicare beneficiaries with incomes below the federal
poverty level who did not receive Medicaid assistance
spent, on average, half their incomes on out-of-pocket
health care costs (17).
Historically, a lack of public insurance programs created
obstacles to health care services. For those who could not

Health Care Systems: Within the United States

afford to pay for private insurance, the costs associated with

health care were larger than most could afford. After
lengthy debate, the U.S. Congress passed legislation in
1965 that established Medicare and Medicaid. Medicare
covers over 95% of the elderly in the United States as well
as many individuals who are disabled. Coverage for the
disabled began in 1973 and is divided in two parts:
1) hospital insurance and 2) supplementary medical
insurance. The total disbursement for Medicare in 1997
was $213.575 billion, and there were 36,460,143
enrollees, of which 32,164,416 were elderly.
The total expenditure for the Medicaid program was
$160 billion in 1996. Of the total amount spent in 1996,
Medicaid payments for nursing facilities and home health
care totaled $40.5 billion for more than 3.6 million
recipients. The average cost per recipient in 1996 was
$12,300, and almost 45% of the total cost of care for
individuals using nursing homes and Medicaid was paid
for home health care (1 3).
Since the enactment of Medicare and Medicaid, there
have been various legislative and administrative changes.
The Balanced Budget Act of 1997 enacted the most
significant changes to Medicare and Medicaid since its
inception, including a capped allocation of monetary
resources to states and the addition of the Childrens
Health Insurance Program. The Childrens Health
Insurance Program set aside $24 billion over 5 years for
states to provide health care to over 10 million children
who are not eligible for Medicaid.
In 1960, public programs paid for one quarter (24.5%)
of all health care spending; by 1988, this share had
increased to 42.1%. Together Medicare and Medicaid
financed $351 billion in health care services in 1996,
which is more than one-third of the nations total health
care bill. Additionally, it represents three-quarters of all
public spending on health care. There has been a
significant increase in Medicare managed care enrollment-from 3.1 million at the end of 1995 to 6.3 million in
1999, leaving approximately 33 million beneficiaries in a
traditional fee-for-service Medicare program.
An area of controversy is the limitation on coverage for
prescription drugs. Spending on prescription drugs is the
fastest-growing piece of personal health expenditures,
amounting to $78.9 billion in 1997. Additionally, spending
for prescription drugs has increased at double-digit rates:
10.6% in 1995, 13.2% in 1996, and 14.1% in 1997 (17).
The reason for this rapid growth, according to Iglehart,
includes: .Broader insurance coverage of prescription
drugs, growth in the number of drugs dispensed, more
approvals of expensive new drugs by the Food and Drug
Administration, and direct advertising of pharmaceutical
products to consumers. The use of some new drugs reduces

403

Health Care Systems: Within the United States

hospital costs, but not enough to offset the increase in

expenditures for drugs (17). In the year 2000, 86% of
health care plans hill have an annual limit on brand and
generic drugs, and there will be increased use of
copayments for prescription drugs (25).
The budget cuts imposed by Congress in 1997 to help
balance the budget have restricted the fees that caregivers
receive for the elderly and disabled. When federal health
programs cut funding significantly, as occurred in the
Balanced Budget Act of 1997, the resulting cutbacks at the
institutional and health-system level trickled down to
providers abilities to provide an acceptable level of
service designed to protect patient safety and foster
appropriate medication use. Partial restoration of the
Balanced Budget Act in 1999 addressed the transition to
an outpatient prospective payment system for hospitals,
payments to skilled nursing facilities and home health
agencies, payments for indirect medical education, and a
number of rural health care provisions.
The dramatic shift of third parties (government, private
health insurance) toward paying for a greater and greater
proportion of personal health care services has led to a
paradigm shift in attitudes and actions toward health care
financing and cost control. Several approaches have been
adopted in the governmental sector to slow the increases in
costs and expenditures. The most dramatic of these has
been the introduction in 1983 of the prospective payment
system (PPS) to curb the growth in hospital costs and
expenditures. By imposing prospective limits on Medicare
payments to hospitals through a system of reimbursing
average costs of specific diagnoses, hospital utilization has
decreased dramatically. The average length of stay and
admission rates in community hospitals of elderly patients
(those covered by Medicare) dropped sharply after the
introduction of PPS (13).
Because of cost-containment strategies of both the
private and governmental sectors, hospital utilization has
declined. This has resulted in a decline in the number of
patient beds, the average length of stay, and patient bed
census (7). The present predominant view is that
hospitalization of any patient, regardless of revenue source,
is to be avoided wherever possible. Only those patients for
whom hospitalization can be fully justified are admitted.
As much as the financing of Americas health care
system is a major issue on the policy agenda of the nation,
so too is the continuous question about the relationship
between the costs and the outcomes of care. As costs
increase, the numbers of policy analysts, organizations,
and governmental agencies calling for a better definition of
the cost-outcome relationship has sharply risen.
Cost-effectiveness and cost-benefit analyses are frequently mentioned in academic and policy-analysis

circles. These notions center on careful examination of

the costs and their corresponding outputs. Eisenberg (26)
defines cost-effectiveness analysis as the measure of the
net cost of providing service (expenditures minus savings)
as well as the results obtained (e.g., clinical results
measured singly or a series of results measured on some
scale). Cost-benefit analysis determines whether the cost
is worth the benefits by measuring both in the same units
(26). Such analyses will be critical, as future policy
decisions are made with regard to the collection,
allocation, and utilization of finite resources in the health
care system for the enhancement of health status of the
American people.
Private-sector strategies and governmental plans to
curb health care costs have not escaped criticism.
Ginsberg, for example, argues that the notion of for
profit hospital chains has severe limitations with respect
to garnering large proportions of market share and,
consequently, greater profits (27). He bases this view on
the limited amount of private funding available for
hospital care. On the other hand, he sees this sector as
being able to grow in the area of nursing homes and other
businesses related to the care of the elderly.

There are three classes of individuals who have open

access to and can derive some form of services from
Americas health care system:
0

Those who receive support from governmental sources

because of specific entitlements (indigents, elderly, and
veterans)
Those who are provided with basic health insurance
coverage from their employers
Those who choose to cover their expenses from out-ofpocket payments

There are, however, those who have no specific

financial support or capacity to pay for health care services
and who are not eligible for any type of entitlements.
These individuals must rely on some form of charity care
or services. In addition, there are those who, for reasons of
geographic remoteness or total inability to gain access,
have no access to health care services. This group
represents a complex, resource-based demand model,
which also has an equally complex pattern of health care
system and services-utilization requirements.
With increasing health care costs and consequent
increases in insurance premium costs, gaining access to

Wealth Care Systems: Within the United States

404

health care services without incurring personal costs has

become more difficult. Not all services are covered for
individuals in the federal Medicare and Medicaid
programs. Moreover. there are strict limitations on the
extent of services offered in these programs. A similar set
of restrictions may be found in private-sector health care
coverage strategies. Because few insurance programs and
none of the federal programs provide coverage for
unlimited long-term care, all but the very rich are at risk
of financial ruin.
The health care lexicon includes two new terms to
reflect these problems: underinsured and uninsured. The
underinsured may include the working poor, those
individuals who have jobs and may be covered by a very
limited, if any, health insurance program by their
employers. They are likely low wage earners and those
receiving incomes at. or slightly above, the poverty level.
Typically, they do not qualify for Medicaid entitlements,
do not have employer-paid health insurance benefits, and
cannot afford (or choose not to purchase) third-party
coverage for payment of health care services.
There are no specific policy plans available to finance
uninsured and underinsured care. Whether planned as
charity care or unplanned as financial loss. the price tag
for uncompensated care in the United States was $18.5
billion in 1997, which is 6% of the total of hospital
expenses (28). This percentage has remained constant
since 1984. when the percentage of total expenses for
uncompensated care was also 6% (8).
Reduced payments and high levels of uncompensated
care have led to the closing of hospital facilities in both
urban and rural blighted areas, making access to care even
more difficult for some. Whiteis and Salmon (29) refer to
this phenomenon as disinvestment in the public goods.
Because privately owned and not-for-profit hospitals and
private clinics, pharmacies, and physicians offices must
rely on their own financial soundness. any threat to that
foundation may lead to closure.
The amount of uncompensated care is magnified in
areas where serious social problems exist because health
status is directly related to social status. Health status
should be examined in broad terms by reviewing
morbidity and mortality data available for the whole
population. The life expectancy of people who live in the
United States has grown by almost 10 years, from 68.5
years in 1936 to 76.1 years in 1996. Women were expected
to live to 79.1 years in 1996, whereas the average for men
was 73.1 years (11). The leading causes of death in 1996
among people living in the United States were (1 1):
1. Heart disease (733,361 deaths)
2. Cancer (539,533 deaths)

3.
4.
5.
6.
7.
8.
9.
10.

Stroke (169,942 deaths)

Pulmonary diseases (108,027 deaths)
Accidents (94,948 deaths)
Pneumonia and flu (63,727 deaths)
Diabetes (61,787 deaths)
AIDS (31,130 deaths)
Suicide (30,903 deaths)
Liver disease (25,047 deaths)

Infant mortality, another measure of the health status of

a nation, stated as the number of deaths per live births, was
7.2 per 1000 live births in 1997 compared to 9.9 per 1000
live births for 1988. Overall, these figures are comparable
to those of the major, industrialized nations of the world.
Major morbidity in the United States is currently
centered on diseases of life style. These morbidities
contrast sharply with disease patterns prevalent during the
early part of the 20th century. Outside of AIDS and other
sexually transmitted diseases, infectious diseases represent
a small proportion of prevalent morbidity. Rather, lifestyle diseases, associated with smoking, poor nutrition, a
sedentary life style, alcohol and other chemical consumption. homicides, suicides, and accidents, represent the
majority of morbidity in the United States. Significant
preventive strategies can markedly reduce the incidence,
prevalence, and mortality associated with these health care
problems.
Not surprising, in areas with high concentrations of
indigent people, there are similarly high concentrations of
uninsured individuals requiring intense health care
services. These areas exist in both rural and urban settings.
Emergency rooms have become a major resource for
primary health care services in areas where physician
office services or other service providers (clinics) are not
available because of location, cost, or quality. Emergency
rooms have also become providers of high-intensity care
for victims of gun shot wounds, drug overdoses,
communicable diseases, and other trauma associated with
poor social conditions. Much of the care in emergency
rooms is uncompensated because the quality and amount
exceed the allowable reimbursement. Some trauma centers
in economically blighted areas have been closed (30).
Hospitals in inner cities and blighted rural areas also
care for a higher proportion of at-risk patients than
hospitals in the for-profit sector generally located in more
affluent areas (29). In fact, affluent hospitals sometimes
dump their uncovered patients on charity care and other
public hospitals in order to reduce their financial risks.
This, however, increases the financial risks of public or
charity hospitals. Again, the reimbursement levels under
present schemes for large numbers of at-risk patients
simply do not cover costs; thus, the United States has

405

Health Care Systems: Within the United Stales

recently at a national round table that there is an

urgent
need to i m ~ r o v ehealth care aualitv. The
c
stringency of managed care and a low inflation rate
have slowed the growth of medical spending
appreciably, but a new government study projects
that health care expenditures will soon begin
escalating again and will double over the next
decade. In short, the American system is a work in
progress. driven by a disparate array of interests with
two goals that are often in conflict: providing health
care to the sick, and generating income for the persons
and organizations that assume the financial risk.

witnessed hospital closings, particularly in those areas

where such loss is most noticeable (30).
American health policy continues to grapple with these
issues related to the underinsured and the uninsured (3 1).
A multiple-tiered health care system based on social class
and ability to pay is unacceptable in a nation that boasts
incomparable riches and political agendas of democracy
and rights. Ginsberg (27) notes:
Despite all our efforts of recent years, then, health
care costs continue to increase.. . . There is
undoubtedly waste in the health care system, but
no solid proposals have been advanced to recapture
the SlOO billion, plus or minus, that some believe
can be saved. I believe that we will not reshape our
national health policy agenda unless and until we
achieve a broad consensus on the key issues. Do the
American people, for example, desire to ensure
access to health care for the entire population? In
that case they must agree to pick up a sizable
additional tab, which they have thus far avoided.
The issue of quality health care has become an
increasing issue of concern in the face of cost constraints
and limited access to health care. The Presidents Advisory
Commission on Consumer Protection and QualiQ in the
Health Care Iiidustq (32) states that the purpose of the
health care system must be to continuously reduce the
impact and burden of illness, injury and disability and to
improve the health and functioning of the people of the
U.S. According to the Commission, there are basic
characteristics of health care that, as a nation, we should
strive to achieve. The Commission has created Guiding
Principles for the Consumer Bill of Rights and
Responsibilities for the health care of people in the
United States. These include the following:
0
0

All consumers are created equal.

Quality comes first.
Preserve what works.
Costs matter.

LT

Suggestions for broad reform, which address the financial,

access. and quality of care issues for Americas health care
system, have emerged during the past decade. Iglehart
emphasizes the irony of the American health care system.
He writes (17):
By many technical standards. U.S. medical care is the
best in the world, but leaders in the field declared

The Presidents Commission (32) outlines areas in

which the American health care system could be improved
in light of the reality that many individuals receive
substandard care and 44.3 million individuals are without
health insurance coverage. This commission outlines
several types of quality problems including avoidable
errors, underutilization of services, overuse of services,
and variation in services. Based on the reality of these
quality problems, the Commission recommended that the
initial set of national aims should include (32):

Reducing the underlying causes of illness, injury and

disability
Expanding research on new treatments and evidence on
effectiveness
Ensuring the appropriate use of health care services
Reducing health care errors
Addressing oversupply and undersupply of health care
resources
Increasing a patients participation in his or her care

The Presidents Commission engages a broad consumer

advocacy movement in public and private sectors calling
for a major reform of the U.S. health care system to improve
access to care for more individuals living in America.
Consistent with previous patterns, however. these calls
have only led to incremental adjustments in policy and
slight quality changes in direction. The major problems, for
the most part, remain unaffected. Although broad based
health care reform efforts have been unsuccessful, market
forces and more targeted legislation and regulatory efforts
have changed the face of health in the 1990s.
The 1993-94 Clinton health care reform plan, in its
ideology, provided an ambitious plan to eliminate the
enormous problem of lack of access to health care. It
proposed to guarantee comprehensive health benefits for
all American citizens and legal residents, regardless of
health or employment status. The proposal was unsuccessful due to a number of factors, including its vast scope, the
complicated nature of the plan, and an underestimation of

406

the politics involved with radically reforming health care.

The failure of the Clinton administration health care
reform agenda and the subsequent events to revise the
American health care system are important lessons of
health-care-system related politics.
Unfortunately, since the failure of the Clinton
Administration plan in 1994, the number of uninsured
individuals in America has grown. According to the
Census Bureau, 44.3 million people are uninsured,
comprising about 16.3% of the population. Of those
uninsured, 15.4% are under 18 years of age, and the largest
percentage is among individuals between 18 and 24 years
of age. People of Hispanic origin make up 35.3% of those
uninsured and 43% of the total uninsured population are
not citizens of the United States (6).
The number of uninsured persons is expected to
continue to grow. Proposals for health care reform to
combat this problem include President Clintons proposal
for Medicare buy-in proposals for middle aged adults
and House Majority Leader Dick Armeys (R-TX)
proposal for a refundable tax credit to pay for insurance
for the uninsured. The 2000 presidential campaign opened
the debate for legislation that will improve health care
coverage for the uninsured. This public debate on how to
enhance access to care will stimulate creative ways to
improve the U.S. health care system. However, rhetoric is
not enough; it needs to be translated into programs that
attack the problem.
The essence of the health care financing dilemma is
related to how much a nation wishes to spend, on whom
these funds are to be expended, and by what methods a
relationship among cost. quality, and outcomes might be
determined. In a time when advancing science and
technology is flourishing in the health care field, high
tech medicine will continue to evolve with an everincreasing price tag. Furthermore, the costs of unanticipated and complex disease problems (e.g., HIV/AIDS) add
to the unpredictability of health care system costs. This is
all to say that most policy makers understand what needs to
be done. They are in a quandary, however, in finding the
appropriate and acceptable solution. Hence, it is likely that
costs and expenditures will continue to rise (and, thereby,
increase the percentage of GNP that will be spent for health
care) and that solutions may become even more elusive.
Although some might argue that the available resources
for expenditures on health care are ultimately limited, few
are able to say exactly where that limit is or should be. In
the United States. there has been an expansion of
technologies and procedures based on scientific advancements without a concomitant development of a moral and
ethical policy for determining who might be best served by
such advancements. Rationing of health care services or

Health Care Systems: Within the United States

otherwise limiting access to high cost services, for

example, has resulted from political policy rather than
from deliberated public policy and rational decision
making. This is most notably evidenced in the Medicaid
component of the U.S. health care system.
As cost pressures continue to mount, there will likely be
a return to having patients pay more of the health care
expenditure dollar from their own resources. This will take
the form of higher deductibles and co-insurance payments.
Perhaps returning the burden of health care financing to
the individual will raise the collective consciousness of
American society that there is no such thing as a free
lunch insofar as using and paying for health care services
is concerned. Certainly, this phenomenon has occurred in
social welfare reform in which the programs that have
had mixed success have been restructured to roll
participants off of welfare to work.
On the other hand, there are perhaps no solutions
forthcoming on some of the problems represented in the
arena of health care financing. As Hardin suggests, there is
indeed a class of human problems that have no technical
solution (33). In using Hardins analogies, Hiatt (34)
suggests that nobody would quarrel with the proposition
that there is a limit to the resources any society can devote
to medical care, and few would question the suggestion
that we are approaching such a limit. The dilemma
confronting us is how we can place additional stress on the
medical commons without bringing ourselves closer to
ruin.

These are the principal contemporary features of the U.S.

health care system. A massive societal structure is at once
saviour, behemoth, juggernaut, and question mark. It
certainly will be in a constant state of flux and gradual
change. It therefore bears constant vigilance and careful
guidance by those who derive their livelihoods from it and
those who are the beneficiaries of its caring. Most
importantly, it will require significant pressure from those
who are disenfranchised from it.

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2. Dougherty. C.J. American Health Care: Realities, Rights,
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Tipton, S.M. Habits oftlir Heart; Harpcr & Row: New
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PROFESSIONAL DEVELOPMENT

Veterans Affairs Medical Center,

North Little Rock, Arkansas, U.S.A.

Health services research (HSR) is a relatively new and

evolving field. As the organization and financing of
healthcare has changed, the need for information about
the type and level of care and the effectiveness and quality of care provided in the healthcare system has increased. This chapter provides a definition of HSR, a
historical perspective of the development of. the field and
the relationship between HSR and public health policy,
and a discussion of the profession of pharmacy and its
relationship to HSR. The chapter concludes by highlighting some of the institutions that commonly fund HSR
and journals that publish manuscripts on HSR topics.

Most fields of research can be identified by the academic

degree of the investigators in that area of research. However, health services researchers are identified more by
the work than by the particular degree of the investigator.
This diversity of degrees reflects the many disciplines that
work in the field. As seen in Fig. 1, many disciplines may
be involved in a given HSR project. making it difficult to
succinctly define the field of HSR. In 1995. the Institute
of Medicine (IOM) developed a comprehensive definition
that characterized HSR as a
multidisciplinary field of inquiry. both basic and applied,
that examines the use, costs, quality, accessibility, organization, delivery, financing, and outcomes of health
care services to increase knowledge and understanding of
the structure, processes, and effects of health services for
individuals and populations."'

One way to understand HSR is to examine the differences between HSR and clinical research. Although the
two areas are certainly related as described here, there are
408

differences that distinguish the two. For the purposes of

this discussion, comparisons are made using three categories: 1) study setting, 2 ) subject selection and sampling,
and 3) data sources and measures.
tin
In general, clinical trials study the efficacy of a medication or other treatment under defined conditions. HSR
studies evaluate the effectiveness of care under usual
conditions. Clinical trials are generally conducted in some
type of clinical laboratory. That is, the intervention takes
place in a controlled clinical setting where the process of
care is dictated by the protocol ( i s . , how often patient is
followed. how often and which tests are performed at each
visjt). Any additional healthcare is provided external to
the study setting. In contrast, data in a HSR study are
gathered from the setting where routine clinical care is
provided. Subject sampling and data collection follow a
strict protocol, but the process of care continues according
to the usual clinical practice in that setting.

Subject selection for clinical trials generally consists of a

convenience sample of a specified number of subjects that
exhibit the particular syndrome or disease of interest.
There are generally very strict inclusion and exclusion
criteria that determine eligibility for the study. However,
HSR uses population-based sampling such that all the
subjects who meet a set of criteria are identified and then
a sampling plan is developed to enroll a study sample that
is representative of the population of interest. The population to be studied may be defined by a specific geographic location (e.g.. people living in the Mississippi
delta), by a specific disease (e.g., veterans with schizophrenia). or by the health care payer (e.g., Medicare recipients). It is imperative that sampling occurs in a way
that allows for comorbid diseases, differences in demographic variables, and other natural variations among
Encyclopedia of Clinical Phaumac)~
DOI: 10.1081E-ECP 120006347
Copyright C 2003 by Marcel Dekker, IRC.All rights reserved.

4109

Health Services Research

Health Services

Fig. 1

subjects. Due to the extensive sampling strategies required by HSR, these projects generally require much
larger sample sizes than those used in clinical research.

Data for clinical trials are generally collected directly

from the patient and include detailed clinical information
collected by trained clinicians. These data are often
lengthy and disease specific, and are designed to detect
small variations among subjects. In HSR projects. lay
interviewers may collect data or they may be gathered by
self-report. Secondary data sources such as pharmacy
refill records. paid claims data. or secondary analyses of
data from national surveys are used to address HSR
questions. Given the large samples in HSR data collection, instruments for primary data collection tend to be
shorter and do not detect small clinical differences. Instead, they offer a broad assessment of the patients health,
level of function, and well-being. Some instruments are
rather "generic" and are designed for use in any population (SF-36). Others may be designed for a specific
disease or population (e.g., asthma quality-of-life questionnaire, toddler quality-of-life survey).

ETWEEN HSR AND

Ginzberg provides an excellent review of the history of

HSR and health policy.[21The IOM 1995 report, "Health
Services Research: Work Force and Educational Issues,"
also provides an excellent summary of HSR and health
policy."] Because the funding and conduct of HSR has

been driven by changes in health policy. a brief overview

is provided.
Using a very broad definition, HSR activities can be
found as far back as the late 1800s, consisting primarily of
descriptive surveys of the prevalence of disease and the
number and type of health care personnel and services.
Federal and state government funded most projects, although professional organizations such as the American
Medical Society also paid for and conducted some studies.
One of the earliest true HSR projects began in the 1920s.
Between 1928 and 1932. this landmark study, known as
the Committee on the Cost of Medical Care (CCMC),
produced 27 field studies and final reports that provided
recommendations on many aspects of health care. including hospital planning, enhancing public health, and
improving professional medical education. One report
suggested the use of group medical practice in association with hospitals as a means to provide comprehensive
health care. Some CCMC members strongly supported
a system using a federally funded health care program,
although most favored a system of voluntary health insurance. A significant minority, mostly physicians, firmly
opposed any insurance initiative.
Despite the recommendations of the CCMC. the
federal government did not intervene in the health care
system until the end of World War I1 (WWII).[21During
WWII, most of the United States' resources were diverted
to the war effort. By the time the war was over, it was
clear that US.hospitals had suffered due to a lack of
resources. Not only were the hospitals lacking modern
amenities, but also as the nation moved into suburban
areas, the number and location of hospital beds were inadequate. In the late 1940s, the federal government began
to enact subsidies that encouraged the expansion of the
stock of technology and biomedical knowledge. hospitals,
and health care personnel. This was accomplished through
funding for the National Institutes of Health (NIH) and
programs to increase education of nurses. ancillary personnel, and physicians. In 1946, the Hill-Burton Act provided funding for construction of many new hospitals and
renovation of old ones. This was the first federally mandated health planning initiative and one of the first efforts
to reduce or eliminate shortages of health care facilities in
rural and relatively poor regions of the United States.
From the 1940s to the 1960s, federal healthcare initiatives focused primarily on supply issues with limited efforts to improve funding of healthcare. The 1960s
marked some of the most significant changes in organization and financing of health care and, therefore, in
the development and funding of HSR. In 1965, the
legislation that funded Medicare and Medicaid was
passed, and in 1966, the Office of Economic Opportun-

410

ity (OEQ) was funded. The OEO opened several large

community health centers throughout the United States.
The federal governments new responsibility for funding
and providing healthcare focused attention on the need
to evaluate strengths. weaknesses, and consequences of
these programs. In 1967, Congress enacted a bill that
made it possible for the Secretary of the Department of
Health Education and Welfare (DHEW) to establish the
National Center for Health Services Research and
Development (NCHSR). This new center consolidated a
variety of research activities in the DHEW, and established other centers for health services research through
contractual arrangements with academic institutions and
other organizations. At about this same time, other federal
organizations began funding HSR projects. These included
the Health Care Financing Administration (HCFA) and the
Department of Veterans Affairs. Ultimately, NCHSR was
absorbed into the Agency for Health Care Policy and
Research (AHCPR). which has been renamed the Agency
for Healthcare Research and Quality (AHRQ).
By the 1970s, it was clear that costs for both Medicaid
and Medicare were increasing more rapidly that anyone
expected. Of particular concern was the scope of coverage provided by the Medicaid program and the costbased reimbursement policies for Medicare. Despite only
limited evidence that health maintenance organizations
(HMOs) decreased costs of health care, support was
increasing for use of HMOs in both the public and private sectors. During the mid-1970s, Congress passed a
variety of legislation that made changes to both Medicaid
and Medicare, but was unable to enact any proposal for a
national healthcare program. The concern over costs for
these national programs and the increasing healthcare
costs in the private sector were the basis of several HSR
projects to examine many aspects of health insurance and
the costs incurred in these plans. However, there were
problems in most of the studies, so no definitive answer
was available. Because of the need for better information
in this area, the OEQ agreed to sponsor an extensive
experiment in health insurance.
This controlled trial in healthcare financing, known as
the Health Insurance Experiment (HIE), was one of the
largest and longest running HSR projects ever conducted.
Enrollment of a pilot sample began in 1973, and the last
families completed participation in the project in 1982.
The HIE randomly assigned families to four health
insurance plans that varied the amount of copayment
incurred by the family from 0-95% or to a staff-model
HMO. One of the most notable findings of the HIE was
that free care did not decrease total health care costs. as
some proposed. Rather, plans in which patients received
essentially free care resulted in higher total costs and

Health Services Research

higher costs for hospitalization. The HIE also suggested

that cost-sharing and enrollment in HMOs was most likely
to have a deleterious effect on the health of the poorest
and sickest groups of patients who were enrolled. As the
results of the HIE were published, many private medical
insurance plans were changed to increase the amount of
out-of-pocket expenses incurred by patients.
Despite the changes in the design of healthcare plans in
the 1980s, the costs of medicaid and medicare and the
costs to employers for private health insurance plans increased steadily. By the 1990s, there was growing interest
in healthcare reform. Despite considerable effort by the
Clinton Administration to propose these types of reforms,
opposition in Congress prevented anything except further
tweaking of federally funded plans. In both the public and
private sectors. payers began to emphasize the value obtained for the dollars spent for healthcare. This emphasis
on cost versus value of services is the focus of many
current HSR efforts.

The pharmacy profession can offer considerable expertise

to the field of HSR. Furthermore, recent changes in the
healthcare system mandate that, as a profession, pharmacy must broaden its focus from individual clinical
interventions to include population and system-level interventions and evaluations. The techniques used in HSR
provide vital tools for pharmacy to influence health
policy and, ultimately. delivery of care. Furthermore,
because of their unique skills and perspectives, pharmacists can offer a distinctive knowledge base that can
inform HSR.
When thinking about pharmacy's involvement in HSR,
it is helpful to use seven areas of HSR outlined in the
IOM's 1995 report."' These are 1) organization and financing of health services; 2 ) access to health care;
3) quality of care; 4) clinical evaluation and outcomes
research; 5) informatics and clinical decision making;
6) practitioner, patient, and consumer behavior; and
7) health professions work force. By thinking about the
type of research questions considered in each of these
categories, it is possible to better understand both the
contribution pharmacists can make to HSR and what
HSR has to offer the profession of pharmacy.

HSR has contributed to many proposals for healthcare

reform since the 1960s. These include managed care,

411

Health Services Research

consumer choice, and outcomes and performance monitoring. The field has devised tools and techniques that
have facilitated the development of alternative methods
of paying for health services, such as resource-based
relative value scales for physician services. The recent
emphasis on the provision of clinical pharmacy services
has spurred an increase in studies evaluating the effect of
these services on the costs of are.[^-^] McCombs and
colleagues conducted an extensive study of the impact of
pharmacists services on costs of care.[71This study compared the effects of three models of pharmacy consultation services on hospital admissions, total healthcare
costs, and medication costs. When compared with usual
care, the consultations were associated with a lower likelihood of hospital admission and with lower total healthcare costs for high-risk patients. The consultations that
focused on high-risk patients were associated with lower
costs for office visits but with higher costs for medication.[71 This study is an excellent example of using
HSR tools to provide the kind of evidence necessary to
improve both the organization and financing of pharmaceutical care.

Projects that study access to healthcare evaluate factors

that influence the timely receipt of appropriate care. In the
pharmacy profession, access to care implies access to both
dispensing and clinical pharmacy services. Examining access can highlight the effects of changes in payments for
prescription medications on access to dispensing services.
For example, in 1999, Straub and Straub"] studied access
to retail pharmacies in rural Illinois. This survey showed
that, although current access to pharmacies was good,
changes in reimbursement from third-party payers, demands of managed care, and expanded competition provided threats to access in rural pharmacies. This type of
information is vital to develop health policy that will
maintain access to retail pharmacy services throughout the
United States.
Access to clinical pharmacy services is a somewhat
more difficult issue because barriers to these services are
both geographic and financial. Because pharmacists cannot obtain a provider number to directly bill for clinical
pharmacy services, it is difficult for them to receive the
financial incentives necessary to make this service
widely available. Furthermore, because financial incentives exist only for dispensing services, patients may
have access to clinical pharmacists only in special environments such as inpatient hospitalization or in systems
such as the Veterans Healthcare Administration (VHA)
or HMOs.

Donabedian describes quality of care in terms of the

structure, process, and outcomes of the healthcare system.['] Structure refers to the availability, organization,
and financing of health care programs and the characteristics of the targeted populations. Process encompasses
the transactions between patients and providers during
actual care delivery. Equity, efficiency, and effectiveness
serve as intermediate outcomes of the medical care delivery process, which has the ultimate goal of enhancing
the populations' health and well-being. Major quality
initiatives have adopted this approach. These include the
National Committee on Quality Assurances, Health Plan
Employer Data and Information Set, the Foundation for
Accountability, the Medical Outcomes Trust, the Health
Outcomes Institute, and the Joint Commission for Accreditation of Healthcare Organizations ORYX system.
Relatively little work has explicitly addressed the interactive effects of organizational factors on care delivery and client outcomes. Most HSR has focused on
broad structural organizational variables without studying the mechanisms that may account for differences
in outcomes.
Measurement of quality is an area in which pharmacists could play a key role. Pharmacists in hospitals
and other institutions are often charged with the task of
evaluating quality of medication use in the form of drug
use evaluation. Furthermore, many efforts at assessing
quality of care rely on use of computerized prescription
records."0s' Because of pharmacists' knowledge of clinical aspects of care along with the details of dispensing
of medications and, therefore, the development of prescription records, pharmacists are poised to offer insight
and leadership in quality assessment efforts in a variety of
settings, particularly as it pertains to use of medication.

esearch
Ellwood described outcomes management as a way to
help patients, payers, and providers make rational medical
choices based on better insight into the effect of these
choices on a patient's life.[I2] Clinical evaluation and
outcomes research studies include evaluation of the impact of severity of illness on clinical and economic outcomes, the effect of patient participation in care, the role
of patient preferences in medication adherence, and the
relationship between quality of life and satisfaction. Many
studies address the impact of pharmacist activities on
economic
Some studies also evaluate
pharmacists impact on clinical outcome^."^-'^^ However,
in a literature review of studies that examined the impact

412

Health Services Research

of pharmacists in ambulatory care or community practice,

Tully and Seston found few studies that clearly demonstrated improvement of economic outcomes.[171Only a
minority of the literature reviewed included assessment of
quality of life, patient satisfaction, or functional outcomes
and, when assessed, these parameters were rarely significantly different after the pharmacists intervention. The
authors believed these results were due, in part, to small
sample sizes and problems with research design. It is imperative that studies evaluating the impact of pharmacists
activity pay particular attention to study design, sample
size, and outcomes measurement.

linical Decision ~ a k i n ~
Studies of informatics and clinical decision making concentrate on the benefits of using computerized decision
support systems in clinical practice and in research to
measure outcomes, efficiency, and effectiveness of care.
Decision analysis in clinical research employs probability
analysis to express uncertainty and utility theory to express patient preferences for health outcomes.
Computers have been used as a routine part of pharmacy practice for many years. Pharmacists use this technology in many ways. For example, computers can be
used to interact with physician colleagues, track patient
behaviors, or as tools to evaluate cost and effectiveness of
medication
Pharmacists have also investigated concordance between traditional and computerized patient records, and are now incorporating computers
into patient assessment and educational activities.[20211
This familiarity with the technology positions pharmacists
to provide leadership in using informatics to examine and
improve health services.

ically based, understandable information that will guide

decisions about many aspects of healthcare.
Clinical pharmacy has a long history of influencing
provider behavior through medication formularies, clinical recommendations, drug utilization review, and provision of drug information. Pharmacists influence consumer behavior through patient education and clinical
management strategies designed to optimize clinical outcomes. This experience provides a knowledge base that
can be used to enhance HSR studies that seek to understand and influence patient, provider, and consumer behaviors. Pharmacists can also use the information gained
by researchers in this area to improve the effectiveness
of pharmacy practice.

Health Professions Work Force

HSR also asks questions about the education and supply
of health care workers. For example, a project evaluating
care for rural patients with cancer identified both a
shortage of pharmacists to deliver pharmaceutical care
and raised questions about how well pharmacy curricula
prepare pharmacists to meet the needs of rural patients.[221
Other studies evaluate the number of professionals needed
to optimize costs of care or evaluate the supply and demand of health care w ~ r k e r s . [ Unfortunately,
~~-~~~
these
efforts have not proven particularly successful.[1,26-2s1
Given the increasing concern over shortages of pharmacists, it is important for the profession to work with health
service researchers to develop models to better address
this issue and to study the consequences of personnel

shortage^.[^^-^^]

atient, and Consumer Behavior

Many HSR studies focus on the behaviors of practitioners,
patients, and consumers, and the relationship between
behaviors and the outcomes of care. The study of practitioner behavior includes identifying and understanding
the impact of factors that influence the way providers
make decisions. These factors can include training, experience, confidence level, peer pressure, patient preferences, financial incentives, and organization constraints.
Strategies for changing practitioner behavior are also
examined in this type of study. Investigation of patient
behaviors includes treatment and medication adherence,
preferences for types and delivery of services, and perceived barriers to receipt of health care services. The goal
is to provide information to many types of consumers
(e.g., patients, policy makers, payers, etc.) with scientif-

Funding for HSR projects can be divided into four broad

categories: 1) self-funding, 2) consultation, 3) contracts,
and 4) grants.[331Self-funding is fairly self-explanatory in
that the project is conducted by using resources already
available to the researcher. Data processing and library
services are common examples of this type of resource.
Some institutions may also allow junior researchers to use
datasets already in existence at that institution. An important issue in self-funded projects is that the researchers
time is already paid for, usually by an academic institution. Consultation provides funds that pay for the
professional expertise of the researcher. The researcher
combines this expertise with research activities to address
the clients specific question or problem. Rand Corporation in Los Angeles, California, is one of the most prominent examples of this type of activity. Grants and

413

contracts provide funds to conduct a specific research

proposal. Both may be funded by public or private institutions. The major difference between contracts and
grants has to do with control of the project and the project
funds. In a grant, the principal investigator generally
controls all aspects of the project including study design,
project implementation, disbursement of funds, and
modifications to the original protocol. In a contract, the
funding entity has much more input into all aspects of
the project.
Among federal programs, the Agency for Healthcare
Research and Quality (AHRQ), formerly the Agency for
Healthcare Policy and Research (AHCPR), is the leader
in research to improve quality of care. However, others
such as the Government Accounting Office, Health
Resources Service Administration, HCFA, Office of the
Assistant Secretary for Planning and Evaluation, and
Centers for Disease Control and Prevention also perform
HSR. Individual institutes within the NIH also support
services research. For example, there is a Services Research and Clinical Epidemiology Branch within the
National Institute of Mental Health (NIMH) that funds
services research.
The VHA has had a department of Health Services
Research and Development (HSR&D) since 1976.[341
Since the mid- 198Os, this department has emphasized use
of health services research as a tool to improve the health
of veterans. Funding from HSR&D is primarily for
investigators in the Veterans Administration system, and
consists of both investigator initiated research proposals
and solicited proposals for specific research.
A number of large centers in the private sector are
now offering grant funding for HSR. These institutions
may also conduct HSR. These include the Center for
Studying Health Systems Change, funded by the Robert
Wood Johnson Foundation, and affiliated with Mathematica Policy Research Inc., RAND Health, the Health
and Policy Center of the Urban Institute, and Emergency
Care Research Institute. Key HSR academic centers include the Cecil G. Sheps Center For Health Services Research at the University of North Carolina at Chapel Hill,
the Center for Health Services Research and Policy in
the George Washington University Medical Center School
of Public Health and Health Services. and Michigan
Health Services Research at the University of Michigan.
There are also resources for identifying funding
sources. The Federal Information Exchange provides an
electronic service that uses e-mail to send grant
information to researchers. The Directory of Research
Grants and The Foundation Directory are also excellent
sources for information regarding federal, state, and
private funding institutions. A more complete listing is

available in Health Services Research Methods written by

Leiyu Shi.[331

The specific educational disciplines of health service

researchers are reflected in the wide variety of journals
that now publish health research manuscripts. Journals
that are devoted entirely to HSR include Medical Care,
published by the American Public Health Association;
Health Services Research, the official journal of the
Academy for Health Services Research and Health Policy
(formerly known as the Association for Health Services
Research); and the Journal of Health Services Research
and Policy, published by the Royal Society of Medicine,
Ltd. Many specialized journals are beginning to publish
work based on health services research. For example,
Journal of Health Ecoiionzics, American Journal of Public
Health, American Journal of Medical Qualiiy, and Anterican Journal of Epidemiology will accept manuscripts
based on HSR projects. Prominent clinical journals such
as the New England Journal of Medicine and Journal of
the American Medical Association are also increasing the
number of publications of HSR projects. Pharmacy
journals also contain some HSR articles, including the
American Journal of Health-System Pharmacy, Annuls of
Pharnzacotherapy, and Pharmacotherapy.

Committee on Health Services Research Training and

Work Force Issues. Health Senices Research: Work Force
and Educational Issues; Field. M.J., Tranquada, R.E.,
Feasley, J.C., Eds.; National Academy Press: Washington,
D.C.. 1995.
Ginzberg, E. Health Services Research: Key to Health
Policy; Harvard University Press: Cambridge, Massachusetts, 1991.
Mamdani, M.M.; Racine, E.; McCreadie, S.; Zimmerman,
C.: O'Sullivan, T.L.; Jensen, G.; Ragatzki, P.; Stevenson,
J.G. Clinical and economic effectiveness of an inpatient
anticoagulation service. Pharmacotherapy 1999: 19 (9),
1064-1074.
McMullin, S.T.; Hennenfent, J.A.; Ritchie, D.J.; Huey,
W.Y.; Lonergan, T.P.; Schaiff, R.A.; Tonn, M.E.; Bailey,
T.C. A prospective, randomized trial to access the cost
impact of pharmacist-initiated interventions. Arch. Intern.
Med. 1999, 159 (19), 2306-2309.
Galt, K.A. Cost avoidance, acceptance, and outcomes
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McCombs, J.S.; Liu, 6 . ; Feng, W.; Cody, M.; Parker, J.P.;
Nichol, M.B.; Hay, J.W.; Johnson, K.A.; Groshen, S.L.;
Nye, M.T. The Kaiser Permanenten'SC patient consultation study: Change in use and cost of health care services.
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Every, N.R.; Fihn, S.D.; Sales, A.E.; Keane, A,; Ritchie,
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Rust, G.S.; Murray, V.; Octaviani, H.; Shcmidt, E.D.;
Howard. J.P.; Anderson-Grant, V.; Willard-Jelks, K. Asthma care in community health centers: a study by the
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Ellwood, P.M. Shattuck lecture-outcomes management:
A technology of patient experience. N. Engl. J. Med. 1988.
318 (23), 1549-1556.
Blumenschein, K.; Johannesson, M. Use of contingent
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An overview and review of the literature. Clin. Ther. 1999.
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Dager, W.E.; Branch, J.M.; King, J.H.; White, R.H.; Quan,
R.S.; Musallam, N.A.; Albertson, T.E. Optimization of
inpatient warfarin therapy: Impact of daily consultation by
a pharmacist-managed anticoagulation service. Ann. Pharmacother. 2000, 34 (5). 567-572.
Self. T.H.; Brooks, J.B.; Lieberman, P.; Ryan, M.R. The
value of demonstration and role of the pharmacist in
teaching the correct use of pressurized bronchodilators.
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Hanlon, J.T.; Weinberger, M.; Samsa, G.P.; Schmader,
K.E.; Uttech. K.M.; Lewis, I.K.; Cowper, P.A.; Landsman,
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PHARMACY PRACTICE ISSUES

S
Kathleen M. Bungay
The Health Institute, Boston, Massachusetts, U.S.A.

INTRODUCTION
For many pharmacists, their first encounter with the
terminology quality of life was in the 1986 New
England Journal of Medicine article by Croog et al.]
entitled The effects of hypertensive therapy on the
quality of life. The authors found that antihypertensive
agents had different effects on the quality of life and that
these differences can be meaningfully assessed with
available psychosocial measures. Currently, the clinical
community is more aware of patient-based measures and
the potential uses of health status assessments. Curriculum of many schools of pharmacy now includes some
information on outcomes of patient care beyond just the
traditional biological measures.
This article discusses selected milestones in the
evolution of health status assessments, the health status/
quality of life conceptual framework(s), an introduction
to the scientific basis and evaluation of patient health
status self-assessment questions, and potential future
research and application of health status measures to
patient care, with special emphasis on its role in clinical
pharmacy practice.

DISCUSSION
The act of measurement is an essential component of
scientific research, whether in the natural, social, or health
sciences.[]

Although measurement has always played an essential

role in health sciences, measurement in laboratory
disciplines rarely presented difficulty. As with other
natural sciences, measurement was a fundamental part of
the discipline and was approached through the development of appropriate instrumentation. Subjective judgment played a minor role in the messurement process; any
issue of reproducibility or validity was therefore amenable to a technological solution.
Since the 1990s, the situation in clinical research has
become more complex. The effects of new drugs or
Encyclopedia of Clinical Pharmacy
DOI: 10.1081E-ECP 120006248
Copyright G 2003 by Marcel Dekker, Inc. All rights reserved

surgical procedures on quantity of life are likely to be

marginal.[] Conversely, there is an increased awareness
of the impact of health care on the quality of human life.
Therapeutic efforts in many disciplines of medicine,
especially those increasing numbers who care for patients
with chronic, long-term disease states, are directed
equally if not primarily to improvement of the quality
of life.13] not the quantity of life.
With therapeutic eforts focusing more on improving
patient function and well-being, the need increases to
understand the relationships between traditional clinical
and health-related quality of life (HRQOL), especially
because it is increasingly used as an outcome in clinical
trials, effectiveness research, and research on the quality of
care. Factors that have facilitated this increased usage
include the accumulating evidence that measures of health
status are valid and reliable. In an effort to promote a better
understanding of linking clinical variables to HRQOL,
Drs. Wilson and clear^'^] published a valuable distinction
between basic clinical medicine and social science
approaches to patients health. They also propose a model
to link both, which is discussed later in this article.
In the clinical paradigm, the biomedical model, the
focus is on etiologic agents, pathological processes, and
biological, physiological, and clinical outcomes. The
principal goal is to understand causation to guide
diagnosis and treatment. Controlled experiments are its
principal methodology, and current biomedical research is
directed at fundamental molecular, genetic, and cellular
mechanisms of disease. Its intellectual roots are in
biology, biochemistry, and physiology.
In contrast. the social science paradigm, or quality of life
model, focuses on dimensions of functioning and overall
well-being, and current research examines ways to accu-

aBecause quality of life represents the broadest range of human

experiences, use of this general term in the health field has led to
considerable confusion, particularly because of the overlap with the
more specific concept, health status. To make the meaning more specific
and retain the important aspects of life quality, the term health-related
quality of life is both useful and important.

415

Health Status Assessment

416

rately measure complex behaviors and feelings. Experimental research designs are rarely possible[51 because the
focus of social science is on the way that numerous social
structures and institutions influence individuals. These
models have their foundation in sociology, psychology,
and economics, and use concepts and methods often foreign to clinicians and clinical re~earchers.'~]

TCOME M E A ~ U ~ E ~
During the 1940s, physicians first began to measure
patient functioning; the Karnofsky Functional Status for
Patients with CancerL6] and the New York Heart
Association Clas~ification[~'
were among the instruments
developed during that period. The first health status
measures distinguished among functional states and
included symptoms, anatomic findings, occupational
status, and daily living activities. Studies began in the
1950s when clinicians examined the functional status of
patients with severe disabilities. When social science
methods and clinical expertise came together in the
1970s, the first modern health status questionnaires
emerged. Typical measures of this period include the
Quality of Well Being Scale."] the Sickness Impact
Profile,['] the Health Perceptions Questionnaire,"'] and
the OARS"'] for use in health services and clinical
research as outcome measures. The next generation of
measures developed in the 1980s and 1990s were the
Health Insurance Experiment (HIE) health surveys,"21 the
Duke-UNC Health profile^,"^] the Nottingham Health
P r ~ f i l e , " ~and
]
the Medical Outcomes Study health
surveys.['51 including the SF-36 Health Survey."61
For a more detailed discussion of the history and development of health status assessment, see Refs. [17-191.
Also, for a more exhaustive list of questionnaires, readers
are directed to Spilker."7"8320~221

~ a r i a ~ i ~innMedical
s
Care in Small Areas
The impetus for research on rationality of processes in
health care delivery, an issue that the field of outcomes
research and guidelines development are meant to address,
is typically traced to the work of John Wennberg,[231who
uncovered a phenomenon known as small area variation. In
brief, Wennberg and colleagues noticed large disparities in
the rates of various medical procedures in different
geographic areas. The differences could not be attributed
to differences in the populations, but instead appeared to
indicate differences in physician cultures of different
regions, where certain treatment strategies became the

norm. For example, a 10-fold difference in rates of

tonsillectomy was observed just within the six New
England states.

The Rand
In 1990, when it became apparent in the United States that
health expenditures accounted for 12.4% of the gross
national product, whereas that proportion was 4% in 1980
and that the rate of growth of health care expenditures was
exceeding the rate of inflation as well as growth in our
economy,[251questions surfaced. Does spending more buy
better health? In individual cases, the answer may be an
obvious yes or no, but in the population as a whole as of
1983, the point of diminishing (or absent) returns was
difficult to identify.[12] This quandary prompted the
federal government to support a large-scale controlled
trial, now known as the Rand HIE.[241
One purpose of the HIE was to learn whether the direct
cost of medical care, when borne by consumers, affects
their health. First, the researchers found that the more
people had to pay for medical care, the less of it they
used. Free care had no effect on major health habits
associated with cardiovascular disease and some types of
cancer. Second, the study detected no effects of free care
for the average enrollee on any of the five general selfassessed health measures.
In addition to these remarkable findings, the HIE
presented one of the first major challenges for measuring
health status. A consequence of this challenge resulted in
one of the most extensive applications of psychometric
theory and methods (long used in educational testing) to
the development and refinement of health status surveys.
Researchers developed or adapted measures to evaluate
the effect of cost sharing on health status. At that time, the
comprehensive set included four distinct categoriesgeneral health, health habits, physiological health, and the
risk of dying from any cause related to risk factors.
General health was operationally defined as physical
functioning, role functioning, mental health, social contacts, and health perception^.'^^'
The measurement goal in the HIE was to construct the
best possible scales for measuring a broad array of
functioning and well-being concepts; it demonstrated the
potential of scales, constructed from self-administered
surveys, as reliable and valid tools for assessing changes
in health status. It. however, left two questions unanswered: Can methods of data collection and scale
construction work in sick and elderly populations? In
addition, could scales that are more efficient be constructed? The answer to these questions was the challenge

Health Status Assessment

411

accepted by the Medical Outcomes Study (MOS) investigators.[261

The MOS was a 2-year observational study designed to

help understand how specific components of the health
care system affected the outcomes of care. One of the two
original purposes of the MOS was to develop more
practical tools for monitoring patient outcomes, and their
determinants, in routine practice using state-of-the-art
psychometric techniques. The study and its many implications and conclusions are discussed in detail elsewhere51 and mentioned here for completeness.

ealthcare Research

To enhance the quality, appropriateness, and effectiveness

of health care services, and access to these services the
federal government in the Omnibus Budget Reconciliation Act of 1989 (Public Law 101-239)[27established
the AHCPR. The act, sometimes referred to as the Patient
Outcome Research Act,[*] called for the establishment of
a broad-based, patient-centered outcomes research program. In addition to the traditional measures of survival,
clinical endpoints and disease- and treatment-specific
symptoms and problems, the law mandated measures of
functional status and well-being and patient satisfaction. In 1999, then President Clinton signed the Healthcare Research and Quality Act, reauthorizing AHCPR as
the AHRQ until the end of fiscal year 2005. Presently, its
mission is to improve the outcomes and quality of health
care, reduce its costs, address patient safety and medical
errors, broaden access to effective services, and improve
the quality of health care services.
ummary
Now that we briefly reviewed the history of some of the
origins of health status assessment research and a few of
the important stimuli, we proceed with a brief discussion
of some of the underlying theories and assumptions.
The design of health surveys, consisting of scales
measuring attributes of a person or a populations health,
are supported by underlying theory known as psychometric
theory.r291Health status scales development can also be
viewed as a unique application of the design and theory that
support the creation of educational measurements (e.g.,
Standardized Achievement Tests). A person who studies
these theories and conducts research or measurement of

such attributes as intelligence, pain, mental well-being, or

functioning is usually a doctorate-level research psychologist and can be known as a psychometrician.

Any type of measurement can be boiled down to two

fairly simple concepts: measurement consists of rules
for assigning numbers to objects so as to 1) represent
quantities of attributes numerically (scaling) or 2) define
whether objects fall into categories with respect to a given
attribute (classification). The objects from a psychological
perspective are usually people. The rules indicate that the
assignment of numbers must be explicitly stated. The term
attribute in the definition indicates that measurement
always concerns some particular feature of the objects.
Scales can be created based on a number of different
theories or models. Three commonly referenced scales are
the Guttman scale, Thurstone scale, and Likert-type scale.
Developing questions and scales using any of these
theories requires some assumptions be made. To reduce
error, one measures the extent that the assumptions[301are
met. For example, with the Likert-type scales, one needs
to test that summated rating assumptions are met, or that
the scale achieves maximum reliability and validity with a
minimum number of
Other examples of
assumptions are that each item can discriminate itself
from a different concept (measured by a different scale)
and that its properties converge with other like scale items
with its own concept. One might also address the
reliability of the scale scores and the features of the scale
distributions. For a much more extensive discussion, see
Nunnaly (1994)[291and for examples see papers written
by Bayliss et al.,[301Mc Horney et al.,1321and Wagner.[331
sure
One readily apparent feature of health sciences literature
devoted to measuring health status is the daunting array of
already available scales. Paradoxically, if you proceed a
little further to find an instrument for your intended
purpose, you may conclude that none of the existing
scales is quite right. Many researchers tend to magnify the
deficiencies of existing measures and underestimate the
effort required to develop an adequate new measure.
Perhaps the most common error committed by clinical
researchers is to dismiss the existing scales too lightly,
and embark on the development of a new instrument with
an unjustifiably optimistic and naive expectation that they
can do better. The development of scales requires
considerable investment of both mental and fiscal re-

Health Status Assessment

418

sources. A comprehensive set of standards, widely used in

the assessment of psychology and education, is the
manual called Standards for Educational and Psychological Tests, published by the American Psychological
Association ( 1974).[341In addition to these standards,
there are a number of compendia of measuring scales.[21

Presently, validity is represented as a process whereby

we determine the degree of confidence we can place on
inferences we make about people based on their scores
from that scale. Some different types of validity, a
discussion of which is beyond the scope of this chapter,
are called content validity, criterion validity, and construct validity.

Content Validity
These terms are technical descriptions of the judgment
that a scale looks reasonable. Face validity simply
indicates whether, on the face of it, the instrument appears to be assessing the desired qualities. Content
validity is a closely related concept, consisting of a
judgment as to whether the instrument samples all the
relevant or important content of domains. Nevertheless, a
researcher should be cautions not to dismiss existing
measures based on a judgment of face validity-for
example, if they did not like some of the questions or the
scale was too long. This judgment of face and content
validity comprises only one of several used to decide on
the usefulness, and will need to be balanced with other
evaluations of the measure.

On the surface, the concept of reliability is deceptively

simple. Before one can obtain evidence that an instrument
is measuring what it is intended (validity); it is first
necessary to gather evidence that the scale is measuring
something in a reproducible fashion. The basic idea
behind the concept is an index of the extent to which
measurements of individuals obtained under different
circumstances yield similar results.

Reliability assesses that a test is measuring something

reproducibly; it says nothing about what is being measured; it is necessary, but it is not sufficient, to establish
the usefulness of measures. To determine that the test is
measuring what was intended requires some evidence of
validity. Many variables in health sciences are physical
quantities, such as height, serum cholesterol level, or
potassium. As such, they are readily observable, either
directly or with the correct instruments. The situation is
different when it changes to range of motion or
responsibility of a physician.

bFor more in-depth information on this topic, the reader is directed to

Refs. [2] and [29].

DEFINITIONS
Health
Defining health is vital to developing a strategy for
measuring it. Concepts of health[351can lack clarity yet
commonly hold their dimensionality as a fundamental
feature. Terms used to define health include positive
states-wellness
and normal-and
negative statesdisability and illness.351 Clues to what dimensions
comprise health are found in the definition of health
offered by the World Health Organization (WHO). The
WHO defines health as a state of complete physical,
mental and social well-being and not merely the absence
of disease or infirmity.
Dictionaries also identify
both physical and mental dimensions of health. Two
features of these definitions are crucial; namely, the many
dimensions of health and the range of health states from
disease to well-being.

Quality of Life
Quality of life is a global concept with many meanings. It
is generally advisable to understand the domains included
when the term is used. Quality of life, it has been suggested, involves highly subjective value judgments and is
equated with profound satisfactions from the activities
of daily life.[371Research and measurement of quality of
life have encompassed both objective and subjective indicators involving a wide array of experiences, states, and
perceptions. Cultural, psychological, interpersonal. spiritual, financial, political, temporal, and philosophical dimensions may be incorporated into various definitions.[351
In 1981, Campbell3x1defined 12 dimensions or domains
of quality of life: community, education, family life,
friendships, health, housing, marriage, nation, neighborhood, self, standard of living, and work. Health is but one
domain or one aspect of life or the quality of ones life.

Because quality of life represents the broadest range of

human experiences, use of this general term in the health

419

Health Status Assessment

field has led to considerable confusion, particularly

because of the overlap with the more specific concept,
health status. To make the meaning more specific and to
retain the important aspects of life quality, HRQQL is
both a useful and important term.

odels
Researchers have proposed a number of conceptual
models of the relationships among the components of
HRQOL."5,16s39-441
Wilson and Cleary, who proposed a
model linking clinical variables with HRQQL, argued that
.'the ultimate promise of the ability to measure HRQQL
will not be fulfilled until it has clear applications to clinical
care."[41 Their pursuit of this goal sets their model apart
from previously published models. Their model includes
five levels or subdivisions: biological and physiological
variables, symptom status, functional status, general health
perceptions, and overall quality of life (Fig. 1).
A comparison of different conceptual models is beyond
the scope of this chapter. Because the conceptual model
informs the measurement, each may be slightly different
although some commonly agreed upon and frequently
measured general health concepts can be identified and
discussed. These concepts are: 1) physical functioning, 2 )
mental functioning. 3) social and role functioning, and 4)
general health perceptions. By denoting a measure as a
general health status measure, it is understood that the
questions are not disease or disorder specific, and that they
cover a range of health states from life-threatening

Svmptom

Psychological

/'

conditions to an overall sense of well-being. General

measures evaluate aspects of health relevant to all ages,
races, genders, and socioeconomic backgrounds. The
measures also permit the examination of the benefits of
treatments in comparable units.
Using general health measures, Stewart et al.'451
compared the functional status and well-being of patients
with chronic conditions. They reported the usefulness of
generic (non-disease-specific) health measures for monitoring progress and for use as outcomes in studies of
patients with chronic conditions. The authors maintained
that there are several advantages of general measures of
functional status and well-being over disease-specific
measures. Among these, they noted, first, they are useful
for monitoring patients with more than one condition, and
second, for comparing patients with different conditions
by providing a common yardstick. Last, the same measures can be appropriately applied to both general (well)
and patient (sick) populations, with the advantage of
comparing patient groups (sicker) with the healthy standard of a general population (Fig. 2 ) .

easured Domains of Health:

General Health Status ~ s s e s ~ e n t
Physical function
Physical health is commonly measured in terms of limitations in the performance of or ability to perform selfcare activities (e.g., eating, bathing, dressing), mobility,
moderate or more strenuous physical activities, and bodily
pain. Responses to questionnaire items in this category

PeLality
Motivation

Values

Social and

Fig. 1 Relationships among measures of patient outcome in a HRQOL conceptual model. (From Ref. [4].)

Health Status Assessment

420

--

however, mental health can change long before observable changes in behavior. Furthermore, clinical and social
changes in mental health do not always manifest as distress or cognitive dysfunction. Disease or illness may
cause a loss of zest for life or the feeling that life is less
enjoyable. Capturing such a change requires the presence
of questions that assess psychological well-being; therefore, general measures should encompass the full range of
states in the continuum.[491
Social and role functioning

I.oo

Physical
Role
Social
Mental
Health
Bodily
Functioning Functioning Functioning Health Perceptions Pain

Fig. 2 Health profiles for patients with four conditions. Dotted

line indicates patients with no chronic conditions. GI, gastrointestinal disorder; MI, myocardial infarction. (From Ref. [45].)

generally focus on limitations due to physical health as

opposed to some other cause.
Assessments of physical health often vary in the range
of functioning. Questionnaires that assess self-care often
concentrate on the negative end of the continuum of
physical functioning; some determine different physical
health states, and others determine individual differences
in the level of effort, pain, difficulty, or need for
assistance in performing physical
Thus,
individual patient responses to question may be identical
or may different substantially from one test to another. To
be comprehensive as measures of physical health status
for a population, measures for general use are recommended[461to elicit information concerning activities of
daily living, energy level, satisfaction with physical shape
or condition, and ability to perform vigorous activities.
Questions in those areas are sometimes phrased positively
to extend the measurement scale into the positive range
(how we feel as opposed to the limitations we experience). This allows measurement only of differences in
physical well-being among those free of limitations.
Mental health
These measures often focus on the frequency and intensity of psychological distress (e.g., anxiety or depression), and include the individual's perception of psychological well-being and life satisfaction and an assessment
of cognitive functioning.[481Measures of this domain also
cover the broad range of differences possible in the mental health continuum. Health disturbances commonly
manifest themselves on behavioral and physical levels;

Functioning in interpersonal relationships and in role and

other daily activities are commonly lumped together as
measures of social functioning. However, for evaluating
HRQOL it is better to consider them separately.
Social functioning is defined as the ability to develop,
maintain, and nurture mature social relationships. Our
group has concluded that measures of social functioning
1) reflect physical and mental health status, 2 ) serve to
indicate the need for health care, and 3) reflect
appropriate outcomes of health care.
Usually, social well-being is separated into two areas:
1) whether and with what frequency social contacts are
occurring and 2) the nature of the person's social network
or community. The frequency and number of contacts, as
well as personal satisfaction with those contacts, vary a
great deal amount individuals. Depending on the person,
quantitative data may offer no insight or may offer the
wrong insight. A person's evaluation of the adequacy of
the social network to which he or she belongs may be
more valuable. People who consider themselves part of a
community, family, or neighborhood often have a strong
sense of being wanted, loved, or valued.[501Measures of
personal resources often overlap the mental dimension of
health. The feeling that one is loved or cared for may
assess mental health even more than it measures social
well-being. Some research reviewed by W ~ r t m a n [ ~ ' I
suggested that social circumstances are linked to both
physical and mental health outcomes.[521
Role functioning describes whether a person can meet
the demands of their normal role in life (e.g., formal
employment, schoolwork, housework). Persons not
working in outcomes research often use the terms role
function and social function interchangeably; however, in
terms of measuring HRQOL, they are distinct. A role
function measure seeks to identify situations in which an
individual's health problem directly interferes with the
performance of their everyday role, in contrast to participation in the social interaction and network to which
they belong. For example, arthritis strikes a professional
organist who has a loving and supportive family and a

Health Status Assessment

network of friends. He may not feel isolated or unloved,

and his relationships with his wife and children continue to
be positive. However, to the man for whom music is fuel
for mental, financial, and spiritual well-being, the loss of
his professional role may be devastating. That devastation
is a role function loss. If he then lost the friendships he
developed and maintained through his music, then that
would be loss of social function.
For many people, physical health problems limit role
performance. Occasionally, mental disruption can impinge on role functioning, but measures of this health
dimension seldom detect mental or emotional problems
because patients seldom consider role limitations unless
they are asked about them explicitly. Some questionnaires
ask specifically about limitations of role function due
specifically to personal or emotional problems, in addition
to those due to physical health problems.
Measurement of the impact of health on role activities
has grown, owing in part to legislation and information
provided by the passage of the Americans with Disabilities
Approximately 55 million working-age
individuals (1 8 -65 years of age) have chronic illnesses
and/or impairments. Disabilities are a potential consequence of health problems and signify a partial or total
inability to perform social roles in a manner consistent
with norms or expectations.[531National survey data
suggest that 32% of employed adults have ongoing health
problems that interfere with their ability to perform their
job demands.[j4] Historically, although limited, studies
have used outcomes of work loss or amount of time
missed from work due to illness or treatment.
Role functioning scales usually measure global, rolelevel disability indicators to capture disability in paid
work and/or other activities. However, for some applications, these may be relatively course, distinguishing a
limited range of disability levels. Recently, researchers
introduced a more detailed measure of work productivity
assessing on-the-job impact of chronic conditions and
treatment.[541

General health perceptions

The beliefs and evaluations of a persons over health in
general, rather than a particular mental or physical aspect,
constitute their general health perceptions. Questions in
this area reflect each persons own health preferences,
values, needs, and attitudes, and thereby discriminate
between individuals whose objective levels of physical
and mental health, as defined by other measures, appear
identical. Such self-perceptions are important for two
reasons: 1) reports of behavioral performance do not
capture important subject manifestations of differences in

421

health such as pain, difficulty, level of effort required, or

worry and concern about health; and 2) questions in this
domain inquire about positive feelings or a positive frame
of reference, for example, a favorable health outlook in
contrast to questions from other domains that focus on
measures of limitation, pain, or dysfunction, and are
usually stated in a negative way. Responses in the general
health perception domain are subjective and evaluative.
They are typically ratings rather than reports, for example,
a rating of health from excellent to poor.

Disease-Specific Health tatus ~ ~ s t r u ~ e ~ t s

Often, it is necessary to focus on the particular impact
that a certain disease has on patients. In such cases, general health status tools are inadequate for providing the
information needed. To overcome this limitation, condition- or disease-specific measures are often used instead of or along with a general health status instrument.
The more narrowly focused disease-specific measure
requests detailed information on the patients perspective
on the impact of a disease and its treatment. In addition,
using disease-specific measures allows inclusion of domains of specific interest for the disease under study and
the patients it affects. Among the specific areas previously investigated with disease-specific questionnaires
are sexual and emotional functioning, nausea and vomiting, chronic pain, anxiety and depression, chronic
obstructive pulmonary disease, cardiovascular disorders,
hypertension, epilepsy, benign prostatic hypertrophy, endstage renal disease, diabetes, cancers, AIDS, HIV infection, and migraine.[2055-571The reader is directed to
Refs. [20] and [22] for a more comprehensive listing of
disease-specific questionnaires.
The argument in favor of disease-specific questionnaires is twofold. The first consideration is that, if an
instrument has to cover a wide range of disorders, many
of the questions may be inappropriate or irrelevant for any
one specific problem. The second reason is to keep the
length of the questionnaire manageable. Thus, there will
be fewer, relevant questions to detect real changes within
patients or to detect differences among them.
On the opposite side of the argument, the cost of a
greater degree of specificity is a reduction in generalizab i l i ~ y . ~ ,That
~ ~ ] is, generic scales allow comparisons
across groups of patients with different disorders, severities of disease, interventions, and perhaps even
demographic and cultural groups,[601 as well as being
able to measure the burden of illness of populations
suffering from chronic medical and psychiatric condit i o n ~ , [ ~as
* ] compared with a healthy population. This is
much harder to do when each study uses a different scale.

422

Furthermore, because any one generic scale tends to be

used more frequently than a given disease-specific instrument, there are usually more data available regarding
its reliability and validity.

As the integration of patient-based outcome measures into

all sectors of health care expands, the need arises for
instruments capable of capturing data across cultures. In
recent years, a rapid increase in the number of available
translations of both generic and condition-specific instruments has occurred throughout the world.[611The rise in
demand for translated instruments is partially driven from
the need to aggregate data from two or more cultures in
clinical trials.
The IQOLA Project is translating, validating, and preparing norms for the SF-36 Health Survey for use in
multinational clinical trials and for other international
studies.[62-661Based at the Health Assessment Laboratory
at New England Medical Center, the project began in
1991, with sponsored investigators from 14 countries.c In
addition, researchers from more than 30 other countries
are translating and validating the SF-36 using IQOLA
Project methods.d
The general process of translating an instrument is
very complex, and is oversimplified here to give the
reader a brief introduction only. The instrument is translated from the source (original) language to the target
language (forward translation). Several forward translations are conducted by translators residing in the target
country who are familiar with the tenets of the field of
health outcomes. Then a consensus meeting with experts
is convened to evaluate the efforts. A quality control step
exists to ensure that the target version is equivalent to the
source version, both conceptually and linguistically. This
usually includes a backward translation from the target
language to the source (original) language. The instrument is then pretested, which marks the final stages of the
translation process.

Australia, Belgium. Canada, Denmark, France, Germany, Italy, Japan;

The Netherlands. Norway, Spain. Sweden, United Kingdom (English
version). and United States (English and Spanish versions).
dArgentina, Bangladesh, Brazil, Bulgaria. Cambodia, China. Croatia,
Czech Republic, Estonia. Finland. Greece, Hong Kong. Hungary,
Iceland. Indonesia. Israel. Korea, Mexico, New Zealand, Poland,
Portugal. Romania, Russia, Singapore, Slovak Republic. South Africa,
Taiwan. Tanzania, Turkey, United Kingdom (Welsh), United States
(Chinese, Japanese, Vietnamese), and Yugoslavia.

Health Status Assessment

When you ask a patient or any person, how are you?,

what type of information do you expect in response? Do
you direct the patient in what units to answer? For
example. how are you? . . . I am fine. If prompted, the
respondent could produce a rating of how they think they
are doing . . . On a scale of 1 to 10, I am a 2. Likewise,
the answer could include a reference to the time span on
which they are reflecting when answering your question.
Such as, At this moment, I am just fine, in general my
life is a bit unsettled.
This example underscores and oversimplifies developers thought processes when developing items to
measure the domains of health. A measurement strategy
can be defined to obtain as little or as much information.
Ultimately, the amount of detail in the answers depends
on what one plans to do with the information. The first, I
am fine, is a global assessment. The second I am a 2,
is an example of a rating scale. The third gives you and
example of what one might call a recall period, or more
practically, what time frame do you want the information
from, yesterday, in the past 4 weeks, or in the last year. To
obtain breadth in the answer to your question, you need to
identify the potential extent of the answer, such as
including both the physical and mental dimensions of
health. Last, how much depth do you want in the reply?
Parameters such as rating, breadth, depth, quantity, and
frequency are the details with which measurement experts struggle when developing patient self-administered
health status questions.
Fig. 3 is an example of a mental health status subscale
from the SF-36 Health S ~ r v e y . [ ~ , a~popular
, ~ ~ ] general
health status measure or instrument. The subscale is commonly referred to as the Mental Health Inventory, or the
MHI-5. The five questions are each called an item stem.
The balance of the item consists of the response choices;
which are designed to be the same for many different
items, thus making it less burdensome to the respondent.
The respondent is instructed to answer each question
about the past 4 weeks (the recall period) and indicate
how much of the time (quantity in amount of time).
The response choices are: 1) all of the time, 2 ) most of the
time, 3) a good bit of the time, 4) some of the time, 5 ) a
little bit of the time, and 6) none of the time. Each of the
patients answers to the five questions are assigned a
number between 1 and 6, summed and averaged, and then
converted to a score between 0 and 100, with 100 being
best health and 0 being worst.
Some of the questions require an endorsement such as
how often have you been a happy person. In that case, the

Health Status Assessment

423

These questions are about how you feel and how things have been with you during the past 4 weeks. For each question,
please give the one answer that comes closest to the way you have been feeling. How much of the time during the past 4
weeks?
VI
[31
I41
[51
[el
All
ost
A good bit
Some
A little
None
of the
of the
ofthe
ofthe
ofthe
ofthe
time
time
time
time
time
time
Have you been a very nervous person?
Have you felt so down in the dumps that
nothing could cheer you up?
Have you felt calm and peaceful?
Have you felt downhearted and blue?
Have you been a happy person?

Fig. 3 Example of a mental health scale from the SF-36. (From Ref. [5].)

response all of the time indicates better health.

However, other items are stated so that none of the
time indicates a better health. Such items are reversed
before scoring. An example is how often have you felt
so down in the dumps that nothing could cheer you.
Persons answering none of the time need to be
assigned a scoring indicating better health, or the opposite
direction of the endorsed items.

vanta
srmat

rnent
sional

Self-administered surveys allow the patient to have a

voice in their care. It permits the patient to communicate
to the health care professionals who are caring for them
about what matters most. This may be information that
you need to know but do not have time to elicit. Analogously to providing a common language for patients and
health professionals. the general HRQOL information can
also provide a standard or common language for different
disciplines of health care professionals. For example, a
nephrologist and a psychiatrist can use a common metric
to discuss a dialysis patients emotional health. A standardized method of asking patients about their functioning
and well-being can be efficiently used in treatment decisions and as a monitoring parameter for efficacy and
toxicity. The information may also be a tool or indicator
for compliance assessments.
In addition, HRQOL can be used to add important
information to the evaluation of the effectiveness of an
intervention, in terms that matter most to the patient. For
example, does the 34-year-old otherwise healthy woman
diagnosed with depression who just started an antidepressant feel better or worse? One could just simply ask
her that question when you see her 4 weeks after the start
of her therapy. As pharmacists, we commonly use the
question, Are you having any side effects? If the

patient tells you she has diarrhea, you may form an impression of that diarrhea-seems like a mild side effect.
However, having her answer survey questions about her
functioning can reveal how trivial or nontrivial the impact
of her diarrhea is to her everyday activities. What would
happen if her diarrhea limits her ability to function as the
checkout person in the grocery store? She cannot leave
her post frequently to go to the bathroom and, if she does,
she could be fired and not be able to provide for her two
young children that she is raising alone. The patient sees
the limitation imposed by diarrhea as considerable, and
knowing more about her functioning conveys a different
message to us than just knowing she is having diarrhea. A
discussion employing information from a patient selfadministered health status survey could also lead to the
patient revealing that she has decided to stop taking her
medication. She did not think it was working and the
diarrhea was not worth the hassle.

As pharmacists, we can use evidence from patient selfadministered health status surveys in caring for patients.681A common model used in teaching students to
monitor therapy is to first create a problem list and, for
every problem on the list, develop an assessment and
plan. The diagram in Fig. 4 breaks down the assessment
process. It requires one to write a potential inventory of
all monitoring parameters. It reminds and guides us to
monitor both the efficacy and the toxicity using subjective and objective parameters appropriate for the disease and the treatment.
We can easily incorporate the information from health
status surveys in any of these boxes. Examples are bolded
in Fig. 4. Now, instead of just monitoring clinical
parameters of efficacy and toxicity, we can extend our

424

Health Status Assessment

SUBJECTIVE

OBJECTIVE

EFFECTIVENESS

TOXICITY

Fig. 4 Pharmacist assessment and monitoring therapy with

health status assessment information included into typical

paradigm.

monitoring parameters to include how a patient is

functioning and feeling. For instance, is the patient able
to go to the store and buy food? Do the patients
medications allow them or prevent them from socializing?
Is their role in life supported by the therapy, or is it harder
to do what they normally consider their job, whether
home with kids or in the office.
Imagine that you get a number back just as you would
a laboratory test from a scored survey. Where would you
place it in the existing paradigm? What will do with it? If
the patients physical functioning after cardiac surgery
and a new medication regimen is up 20 points, that could
be a quantifiable part of your subjective information, or it
could be considered in the objective category of effectiveness. However, if that same person still had a mental
health score below 52, thus indicating a high probability
of depression, then that could be reported as toxicity.
Although it could be a consequence of the seriousness of
his treatment (45-year-old man who just suffered a myocardial infarction), it could also be related to his medications. This is just a start; there is much more to be done
to develop the use of these measures in the care of individual patients. However, it seems that the information
on patients functioning and well-being at a minimum can
help pharmacists to better assess compliance and reasons
for noncompliance. It also presents an opportunity to be
better informed about the patient and tailor education
strategies to fit the individual.

Controversies in Using Health

Status ~ s s e s s ~ ~ for
nts
lndividual
Patient Care Decisions
Standardized measures capturing patient perspectives on
their physical functioning, social and role functioning,
mental health, and general health perceptions are likely to
become more acceptable as an additional piece of
evidence on which providers and their patients can make

decisions about treatment and the treatments efficacy.

Mature theoretical model^,^^'^^] sophisticated measurement
and enhanced technology for use in
measurement make the routine use of individual patient
results in their own care more promising than ever before.
Two practical concerns of the critics of use of HRQOL
assessments in individual patient care are: 1) respondent
burden and 2) reliability of scores obtained from shorter
questionnaires. Current researchers struggle with the
competing demands invoked by everyday use requiring
shorter forms and the reliability of a result obtained from
fewer questions. Specifically, concerns are raised about
the reliability of the result and the interpretation. With
popular outcomes measures, the standard error around a
single person estimate is large and not satisfying enough
to ensure stable conclusions.
Modern test theory offers the potential for individualized, comparable assessments for the careful examination
and application of different health status measures. i691
One such theory is item response theory (IRT). Researchers report that IRT has a number of potential advantages
over the currently employed classical test theory in
assessing self-reported health outcomes. Applications of
the IRT models are ideally suited for implementing
computer adaptive testing.i551IRT methods are also reported to be helpful in developing better health outcome
measures and in assessing change over time.[701
Patients increasingly have more access to computer
technology. It is becoming more practical to employ
assessments using a computer. Patients answering questions about a health status concept using dynamic assessment technology are requested only to complete the
number of questions needed (minimizes response burden)
to establish a reliable estimate. The resulting scores for an
individual are estimated to meet the clinical measures
of precision.

CONCLUSION
The study of HRQOL requires a multidimensional approach. Assessments must include components that evaluate, at a minimum, the health concepts of physical functioning, social and role functioning, mental health, and
perception of general health. In addition, the full continuum of these concepts must be included, from the most
limited to the healthiest. Approaches to capture HRQOL
data include the self-administered questionnaire, personal
interview, telephone interview, observation, and postal
survey. The assessment instruments must possess acceptable reliability, validity, and sensitivity, and the investigators and the participants must accept them. Psychometrics

425

Health Status Assessment

is an essential part of HRQOL research, especially in todays research environment that requires shorter, more
focused measures.
Existing health outcomes measures drawn from classic
test theory and emerging approaches based on item
response theory offer exciting opportunities for appreciably expanded applications in biomedical and health
services research, clinical practice and decision making,
and policy development. The research agenda of measurement scientists includes challenges to: 1) refine and
expand measurement techniques that rely on IRT; 2)
improve measurement tools to make them more culturally
appropriate for diverse populations, and more conceptually and psychometrically equivalent across such
groups; 3) address long-standing issues in preferenceand utility-based approaches, particularly in the elicitation
of preference responses and scoring instruments; and 4)
enhance the ways in which data from outcomes measurement tools are calibrated against commonly understood clinical and lay metrics, are interpreted, and are
made useable for different decision makers.
With the advances in measurement that promise to
continue, knowledgeable clinicians will become the
transportation for these measures to inclusion in patient
care. Interpretation, it is suggested, is partially an issue of
familiarity and repeated applications of the measures
would lead to a better understanding. Ideally, a better
understanding of what a patient tells their provider about
their health status can b e used for decision making that
requires the patient to more actively and routinely participate in their own care.

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8.

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PROFESSIONAL DEVELOPMENT

CY
illiam E. Smit
Virginia Commonwea Ith University, Richmond, Virginia, U.S.A.

N
Health systems evolved from a hospital into multiple
facilities and levels of care during the 1980s and 1990s in
the United States. A health system can include more than
one hospital, ambulatory care clinics, physician office
buildings, long-term care facilities, and home care services. The economic forces, both internal and external to
the hospital, led to the development of health systems.
From a pharmacy perspective, the scope (range) of pharmacy services expanded from acute care to ambulatory
care, to home care, to long-term care, and to other diversified pharmacy services. Consequently, positions for clinical pharmacists expanded from acute care to the other
care settings within the health system.

CTIVlTlE

A health system can own and operate its own licensed

community pharmacies. Prescription services and clinical
services can be provided.
Geriatrics and/or Lon
A health system can own and operate its own licensed
long-term care facilities or license beds within the hospital for long-term care.

A health system can own and operate its own home care
services for nursing care, prescription drug products, and
pharmacist services.
Information Service

A simple description of the range of career activities

within health system pharmacy would be acute care, ambulatory care. and home care to administrative pharmacist
positions. A more detailed description of pharmacist positions within the health system is as follows.

Acute care relates to hospitalized patients. Patient care

areas within a hospital include internal medicine, general
surgery, pediatrics, obstetrics and gynecology, critical
care, cardiac care, pulmonary critical care, psychiatry, oncology, and geriatrics.

rnbulatory Care
A health system can own and operate its own ambulatory
clinics and physician offices. The physician component
can be either by staff physicians employed by the health
system or by contract for physician services.

428

A health system can own and operate its own drug

information service (DIS) to serve the drug information
needs of pharmacists, physicians, nurses, and other
professional staffs within the system. In addition to drug
information, the DIS focuses on drug formulary and
pharmacoeconomic issues of drug products and drug use
within the system.

Therapeutic Drug

onitoring Service

A health system can own and operate a centralized therapeutic drug monitoring service (TDMS) to focus on the
application of clinical pharmacokinetics to the care of
patients within the system.

armacy Services
Depending on the size and complexity of the health system, pharmacy management positions will range from the

Encyclopedia of Clinical Pharmacy

DOI: 10.1081/E-ECP 120006175
Copyright G 2003 by Marcel Dekker, Inc. All rights reserved.

429

Health-Systems, Clinical Pharmacy Careers in

director of pharmacy services to supervisor of a segment

of the pharmacy services within the health system. Some
examples of pharmacy manager positions include supervisor of the drug information service, supervisor of the
therapeutic drug monitoring service, supervisor of ambulatory care services, supervisor of community pharmacies,
supervisor of clinical services, and assistant director of
pharmacy services.

TlVlTlE
The typical work settings for clinical pharmacists in a
health system include acute care hospital, ambulatory
clinic, outpatient pharmacy, home care pharmacy, and
community pharmacy.
Clinical practice in the hospital could be in the central
hospital pharmacy, a satellite pharmacy, a pharmacists
office, or a patient care area. The hospital pharmacy is
usually located on a lower floor of the facility, which
places the pharmacist physically remote from the patient,
physician, nurse, and other personnel. Communications
are often by telephone, fax, or information technology
rather than in person. A satellite pharmacy is a pharmacy
area located in the patient care area where drug distribution and clinical services are provided. A satellite
pharmacy places the pharmacist in the patient care area
where drug distribution and clinical services are provided.
A satellite pharmacy facilitates the placement of pharmacists in close proximity to the patients, physicians, and
nurses. A pharmacists office space is often provided as a
location for the pharmacist to provide clinical services
that is in close proximity to patients, physicians, and
nurses. Clinical services can be provided in a drug information center, often located in the hospital pharmacy,
but it may be located in the medical library. Therapeutic
drug-monitoring services may be provided from a pharmacists office location.
Clinical practice in an ambulatory clinic may be provided from an office area within the clinic. The patient,
patient medical record, physician, nurse, and other practitioners are in close proximity to the pharmacists office
area. Examples of clinics in which pharmacists have provided clinical services include family practice, OB-GYN,
anticoagulation, prescription refill, pain therapy, nutrition,
and internal medicine.

The health system may own one or more community

pharmacies. Clinical services can be provided relating to
patient drug therapy counseling for prescription and

nonprescription medications, management of dmg therapy via physician-approved guidelines, monitoring of

drug therapy, and screening tests for hypertension, diabetes, and hypercholesterolemia.

ral
The following list of pharmacist practice activities describes a general clinical practice model:
Clarify prescription orders.
Question inappropriate prescription orders.
5
Answer drug information requests from patients.
* Answer drug information requests from physicians,
nurses, and other health professionals.
Monitor patient drug therapy for safety and efficacy
using a comprehensive patient medication record:
5

Drug-drug interactions.

- Concomitant drug therapies.

- Appropriate drug, dose, and dosage form.
- Patient allergies.

Drug-laboratory test interactions.

Drug-food interactions.
- Abnormal laboratory tests that are drug induced.
- Clinical pharmacokinetics.
-

Provide patient medication counseling.

Provide screening tests.
Participate in collaborative practice agreements for
managing drug therapy.
* Participate in clinical research.
e
5

XPERl
The preferred education for a health system pharmacist is
the doctor of pharmacy degree. A general practice residency is also preferred. Some clinical pharmacist practices prefer pharmacists with a specialty residency. The
American Society of Health System Pharmacists for the
past 25 years has adopted policies and provided programs
to support these preferred education and training programs. When the criteria can be met for board certification, many health systems support clinical pharmacists
in becoming board certified.
Pharmacist clinical expertise requires practice, practice, and more practice. Years, usually three to five, are
often acceptable to health systems in lieu of some residency training. The challenge is to get appropriate clinical practice experience without a residency.

Health-Systems, Clinical Pharmacy Careers in

430

For supervisory positions, three to five years of

practice experience is often required. During the practice
experience, the pharmacist should demonstrate the ability
to achieve results, complete objectives on a timely basis, possess good communication skills, and demonstrate
good working relationships with coworkers, physicians,
and nurses.
For director of pharmacy services, five to seven years
of experience are often required in a similar health system. Additional education and training, such as an advanced residency in pharmacy management or a masters
degree in business administration, are often preferred or
required. Ability to manage resources, personnel, planning, financial, and interprofessional relationships with
good communication skills are often required.

The following sites are examples within health systems

where pharmacist clinical services are provided:
e
e
e
e
e

e
e
e
e
0

e
e
e
e

Career ladders and growth within a health system can be

viewed as longitudinal andlor lateral. Longitudinal would
be from staff pharmacist to director of pharmacy services. Lateral would be clinical pharmacist from acute to
home care.
The usual longitudinal path is staff pharmacist to
clinical pharmacist, to supervisor of clinical services, to
assistant or director of pharmacy services. Each practice
along this path requires demonstrating knowledge, skill,
and the ability to learn more; assuming new responsibilities; and successfully performing the duties and responsibilities of each position. Additional education and
training often will speed the time line for the longitudinal
career path.
The lateral career path relates to clinical practice at
different patient care levels or settings. Acute care to
ambulatory and/or home care was often required in the
1990s as health systems expanded ambulatory and home
care services and reduced acute care services.
Directors of pharmacy may be asked to assume the
management of other departments and programs within
the health system. The pharmacy director may continue as
director or may give up the management responsibility for
pharmacy services.

A~VANTAGESOF W ~ R K ~ NINGTHE

Several of the obvious advantages for working as a pharmacist in a health system include:
e
e
e
c
e

e
e

e
e
e

ClST
E
Pharmacist clinical services can be provided at any site or
location of patient care. These services are provided directly to patients or indirectly to patients through the
nurse and/or physician.

Acute care hospital in the patient care area(s).

Critical care unit.
Pediatrics hospital.
Neonatal intensive care unit.
Long-term care facility.
Family practice physician office.
Ambulatory care clinic.
Home care services pharmacy.
Community pharmacy.
Outpatient pharmacy.
Drug information services.
Therapeutic drug monitoring service.
Oncology.
Hospice.

Direct access to patients and patient information.

Availability of physicians and nurses.
Patient care environment.
Levels of care-primary, secondary, tertiary.
Resources to support pharmacist clinical services.
Patient care quality assurance activities for pharmacist
participation.
Hospital and medical staff committees for pharmacist
participation.
Opportunities for clinical research.
Opportunities for participation in education programs
for physicians, nurses, and patients.
Provision of drug information on a daily basis.
Participation in therapeutic drug-monitoring services.
Collaboration with pharmacist colleagues in clinical
practice.
Participation in teaching programs for pharmacy
students and residents.
Demand to know acute care pharmacotherapy.

These examples translate into a demand for the pharmacist to know pharmacotherapy and a requirement to
update clinical therapeutics knowledge and expertise; to
collaborate and work effectively and efficiently with
physicians, nurses, and pharmacist colleagues in providing services and care to patients; and to participate in the

43 1

~ e a ~ ~ h " ~Clinicat
y ~ ~ Pharmacy
c ~ ~ s , Carecrs in

many varied activitie5 to provide yuality care to patientc

at different level\ ot care

What is the job satisfaction and morale of the pharmacist staff?

How arc pharmacy technicians used in the pharmacy
operations'?
What i \ the compensation and benefit package'?
What i j the strategic plan for the health \ystem and for
the pharmacy services?

A broad categorintion or hospitals is government and

nongovernment. Government hospitals are federal, state,
and local. Nongovernment hospitals can be categoriLcd
into nonprofit and proprietary (for-profit). A teaching
hospital is one that provides a postgraduatc education
program for physicians. All hospitals exist to provide
services and care to the patients being served. Some of the
key differences between hospitals include the management decision-making process, type of medical staff,
scope of patient services to be provided, size, and financial objectives and strength of each hospital. Thcrc is
not an existing method to determine which types of
hospitals provide more pharmacy and pharmacist clinical
services as there are too many variables that determine the
existing scope of pharmacist services. In general, every
hospital needs more clinical services from the pharmacy
department and staff than currently exist.
Some questions to consider whcn looking at a health
system for possible cmploymcnt include the following:
What is the existing scope of pharinacist clinical
services? What types of services? How long havc they
been provided?
Is the hospital a teaching hospital'?
Does the pharmacy havc an afliliation with a school
of pharmacy?
Docs the health system provide pharmacy residencies?
What is the pharmacy director's philosophy regarding
pharmacist clinical services?
How docs the pharmacy facilities look regarding to
size, organization, cleanliness, automation, and drug
information resources'?
Docs the medical staff and health-system administration support pharmacy services and pharmacist clinical
practice activities?

The answers to these and similar questions should convey whether the health system being considered will provide an environment for clinical practice, job satisfaction,
and opportunities for growth and career advanccmcnt.

PI

Some key factors for seeking pharmacist employment in

a health system relate to the opportunities to provide
clinical services directly to patients, to collaborate with
physicians and nurses, to copc with the personal challenge t o maintain and expand clinical pharmacotherapy
knowledge and expertise, to change practice settings for
the different levels of care and job satisfaction, and to
be viewed as an essential health care practitioner by the
institution, physician, and nurse colleagues. The personal
satisfaction from providing clinical services that benefit
patients is the best reward for working in a health-systein environment.

ACCP Guideline, Practicc guidelines for pharmacotherapy specialists. Pharmacotherapy 2000. 20, 487 490.
ACCP Position Statement. Position papcr on critical carc pharmacy services. Pharmacothcrapy 2000. 20, 1400 1406.
ACCP While Paper. Clinical pharmacy practice in the noninstitutional sctting. Pharmacotherapy 1992. 12. 358-364.
ACCP White Paper. Establishing and evaluating clinical pharmacy services in primary carc. Pharmacotherapy 1994, 14,
743 7 58.
~

PHARMACY PRACTICE ISSUES

Carl

I. Tullio

Pfizer, Inc., Yorktown, Virginia, U.S.A.

Healthy People 2010 is a national health promotion and

disease prevention program aimed at improving the health
of all Americans. Progress in reaching these goals will be
measured using 467 objectives organized under 28 focus
areas. Healthy People 2010 is important to pharmacists
because many of the objectives involve the use, or the
need for proper use, of medications. This article provides
a short history of this program. Using diabetes as an
example, it explains the content of the focus areas, then
reviews the goals and how progress toward them is
assessed. Finally, the implications for pharmacists are
presented. (All of the information in this article is from
the Healthy People 2010 Web site, http://www.health.
gov.healthypeople/.)

201

Healthy People 201 0: Objectives f o r Improving Health,

the third decade-long national initiative, builds on the
achievements of the past two decades. In 1979, the first
report, Healthy People: The Surgeon Generals Report on
Health Promotion and Disease Prevention, put forth
national goals for preserving independence for the elderly
and reducing premature deaths. A second report, in 1980,
Promoting Health/Preventing Disease: Objectives f o r the
Nation, provided more than 200 health objectives for the
United States to achieve over the next 10 years. Healthy
People 2000: National Wealth Promotion and Disease
Prevention Objectives, released in 1990, continued this
program and identified health improvement goals and
objectives to be attained by the year 2000. The Healthy
People 2010 initiative continues in this tradition as a tool
to improve our nations health into the first decade of the
2 1st century.
One of the most encouraging lessons learned from the
Healthy People 2000 program was that we, as a nation,
can make dramatic progress in improving the nations
health in a relatively short period of time. For example,
432

during the last decade, significant reductions were

achieved in infant mortality. Childhood vaccinations
are at the highest levels ever recorded in the United
States. Fewer teenagers are becoming parents. Overall,
alcohol, tobacco, and illicit drug use is leveling off. Death
rates for coronary heart disease and stroke have
declined. Significant advances have been made in the
diagnosis and treatment of cancer and in reducing
unintentional injuries.
But there is still much progress to be made. Diabetes
and other chronic conditions continue to present a serious
obstacle to public health. Violence and abusive behavior
continue to ravage homes and communities across the
country. Mental disorders continue to go undiagnosed and
untreated. Obesity in adults has increased 50% over the
past two decades. Nearly 40% of adults engage in no
leisure time physical activity. Smoking among adolescents has increased in the past decade. And HIV/AIDS
remains a serious health problem, now disproportionately
affecting women and communities of color. The development and implementation of Healthy People 2010
will be the guiding instrument for addressing these health
issues, reversing unfavorable trends, and expanding on
past achievements.

EV
Suggestions for Healthy People 2010 objectives were
gathered from a variety of diverse organizations and
people using a series of national and regional meetings.
On two different occasions in the late 1990s, the American public was given the opportunity to express its
views and opinions. More than 11,000 comments were
received from every state in the Union, plus the District
of Columbia and Puerto Rico. Using this input, the final
Healthy People 2010 objectives were developed by teams
of experts from various federal agencies under the
direction of Health and Human Services Secretary Donna
Shalala, Assistant Secretary for Health and Surgeon
General David Satcher, and former Assistant Secretaries
for Health. The Office of Disease Prevention and Health
Eizcjclopedia of Clinical Pharmacy
DOI: 10.1081E-ECP 120006190
Copyright 0 2003 by Marcel Dekker, Inc. All rights reserved.

433

Healthy People 2010: Objectives for Improving Health

Promotion, U.S. Department of Health and Human Services, coordinated and oversaw the entire process.

ENT
The two overarching goals of Healthy People 2010 are
the elimination of disparities in health status among racial
and ethnic groups and the improvement in the years and
the quality of life for people of all ages. Progress in
attaining these goals will be measured using the 467
objectives in the 28 Focus Areas (Table 1). Each focus
area contains its own overarching goal. For example, the
goal of the diabetes section states, Through prevention
programs, reduce the disease and economic burden of
diabetes, and improve the quality of life for all persons
who have or are at risk for diabetes. After listing the
goal, an overview of the issues, trends, disparities, and
opportunities for action is presented. If the topic was
included in the previous program, Healthy People 2000,
interim progress toward the objectives is detailed. Using
the diabetes example, there are five objectives in the

previous initiative. As Healthy People 2000 draws to a close,

one objective is trending toward the goal, while the other four
are trending away from the goal.

Next, the focus area objectives for 2010 are presented.

Each focus area contains varying numbers of objectives.
Many of the objectives are aimed at interventions designed to reduce or eliminate illness, disability, and
premature death among individuals and communities.
Others focus on broader issues, such as improving access
to quality health care, strengthening public health services, and improving the availability and dissemination of
health-related information. In the diabetes example, the
number of objectives was increased from 5 in the 2000
program to 17 for the current program. Each objective
(e.g., increase the proportion of persons with diabetes
who receive formal diabetes education.) lists a target
(e.g., 60%) for the year 2010, the rationale behind its
focus, and the national data tables from which the
measurements will be extracted. Each focus area ends
with a listing of related objectives from other focus
areas, an explanation of the terminology used, and the
references employed.

Fable 1 Focus areas for Healthy People 2010

~~

Access to quality health services

Arthritis, osteoporosis, and chronic back conditions
Cancer
Chronic kidney disease
Diabetes
Disability and secondary conditions
Educational and community-based programs
Environmental health
Family planning
Food safety
Health communication
Heart disease and stroke
HIV
Immunization and infectious disease
Injury and violence prevention
Maternal, infant, and child health
Medical product safety
Mental health and mental disorders
Nutrition and overweight
Occupational safety and health
Oral health
Physical activity and fitness
Public health infrastructure
Respiratory diseases
Sexually transmitted diseases
Substance abuse
Tobacco use
Vision and hearing
(Ref. http://www.health.gov.healthypeople/.)

In order to periodically assess the health of the nation, a

set of leading health indicators was developed for the first
time (Table 2). These indicators, which address major
public health concerns, were chosen based on their
ability to motivate action, the availability of data to
measure progress, and their relevance as broad public
health issues. For each of the leading health indicators,
specific objectives from Healthy People 2010 were
selected and will be used to track progress. This small
subset of measures will provide a snapshot of the health of
the nation. Even though the leading health indicator may
have the same name as a focus area, the indicator may
Table 2 Leading health indicators for Healthy People 2010
Access to health care
Environmental quality
Immunization
Injury and violence
Mental health
Overweight and obesity
Physical activity
Responsible sexual behavior
Substance abuse
Tobacco use
(Ref. http://www.health.gov.healthypeople/.)

434

contain only a few of the focus areas objectives and may

even contain objectives from a related focus area. For
example, the tobacco use focus area has 21 objectives,
while the tobacco use leading indicator follows only 2 of
the objectives. The indicators will highlight achicvements
and challenges throughout the next decade while serving
as a link to the 467 objectives of the Healthy People 201 0
program. The leading health indicators are intended to
help thc populace more easily understand the importance
of health promotion and disease prevention. They are also
aimed at encouraging wide participation in improving
health in the next decade.

Healthy People 2010 is important to pharmacists in all

arcas of practice. The focus areas and their objectives
address not only clinical issues but also social issues. As
pharmacists push forward into true pharmaceutical care,

ealthy People 2010: Objectives for Improving Health

the entire patient must he considered, not just the medical

management. Healthy Pcople 201 0 provides thc information needed to help pharmacists develop services that are
aligned with national goals.
For detailed information, the full text of Healthy
People 2010 Conference Edition (Volumes 1 and 2) is
available online at http://www.health.gov.healthypeop1e/.
A CD-ROM version (B0071) can bc purchased from
ODPHP Communication Support Center, P.O. Box
37366, Washington, D.C. 20013-7366, (301) 4685960. Limited numbers of the print version (B0074)
are also available from the ODPHP Communication
Support Center.

Healthy People 20 10: Objectives for Improving Health. http://

www.health.gov.healthypeople/ (accessed October 10, 2000).

PROFESSIONAL DEVELOPMENT

Donald J. Filibeck
Mt. Carmel Home Infusion, Columbus, Ohio, U.S.A.

The practice of clinical pharmacy in the home care/home

infusion setting is a challenging, but rewarding practice
site. The pharmacist is a vital member of the home care
team, which includes the patient and/or their caregiver,
the physician, the home care nurse, and various other
support personnel (e.g., pharmacy technicians, customer
service personnel, billing personnel). The practice sites
vary greatly, and many clinical, operational, and marketing opportunities exist.

at home looks good, as it is approximately one-third as

costly as providing care in the hospital.
As an alternative, some infusion pharmacies also
provide infusion therapies in an ambulatory cliniclike
setting. This arrangement has the advantage of providing
services to patients in a supervised setting. It allows
several patients to receive their infusions concurrently,
therefore making more efficient use of the organizations
staff, particularly nursing.

RMACIST IN HOM

Home infusion therapy involves the administration of

medications using the intravenous, subcutaneous, or epidural routes. Therapies administered at home include
antiinfectives, chemotherapy, pain management, parenteral or enteral nutrition, and immunologic or biological
agents. Many different diagnoses are treated at home,
including many infectious diseases (bacterial, fungal, or
viral), gastrointestinal diseases, immunologic disorders,
and cardiac diseases (e.g., congestive heart failure).-]
Home infusion therapy has proven to be a safe and
effective alternative to patients receiving care in hospital
settings. For most patients, receiving treatment in the
home (or in an outpatient clinical setting) is preferable to
being kept in a hospital.
Whenever a patient starts on home infusion therapy, a
prescription from a qualified physician responsible for the
care of the patient is needed. Home nursing services are
also generally provided to ensure that the proper patient
education and training occurs, and to provide ongoing
clinical monitoring of the patient in the home, along with
the pharmacists clinical interventions.
From a business perspective, the home infusion market
is projected to have annual revenues approaching $4.5
billion (year ending 2000). The market continues to experience cost-containment pressures (as does the entire
healthcare market); however, the future for providing care

Encyclopedia of Clinical Pharmacy

DOI: 10.1081E-ECP 120006263
Copyright 0 2003 by Marcel Dekker, Inc. All rights reserved.

The staff pharmacist may or may not have an advanced degree (i.e., Doctor of Pharmacy degree). Although a PharmD degree is not required, it does ensure
that the pharmacist has a good, sound clinical education. More important is the persons ability to think
quickly when asked difficult questions or when in difficult situations; to interact professionally with a wide
range of individuals (both clinical and nonclinical); and
to be able to work with little supervision in an often
unstructured environment.
As a manager, when hiring, the persons previous
work history should be evaluated for these abilities.
However, experience working in the home care environment is not an absolute requirement. There are pros
and cons to hiring someone with experience. The person
must be licensed in the state in which they are practicing
and must meet all continuing education requirements.

WORK E N V I ~ O N M ~ N T S
Typical work environments are office-type settings where
the pharmacist is working alongside many different individuals. The sites may be free standing (located in light
industrial or suburban office parks) or located on a health
system campus. Many health systems provide home care/
home infusion services as part of the for-profit arm of the
system. In those cases, the home infusion provider pro-

435

436

Home Care, Clinical Pharmacy Careers in

vides service for only those patients being discharged

from the hospital.
For-profit home infusion providers range from singlesite, private companies to multiple-site, million-dollar
companies. All home care providers are licensed by the
state and can chose to become accredited by several accrediting bodies (e.g., Joint Commission on Accreditation
of Healthcare Organizations (JCAHO), Accreditation
Commission for Health Care, Inc. (ACHC), Community
Healthcare Accreditation Program (CHAP)). Accreditation is a requirement for many insurance companies to
serve as a provider for their members.
An advantage of working in home care is the flexibility
in hours and activities that the home care environment
offers. Positions are available that range from PRN or, to
as needed, to part and full time. As needed positions are
often used to help cover vacations and scheduled time off
or on-call activities. Part-time positions can range from
1 or 2 days per week to 4 or 5 . Average hours per day are
8 or 10 depending on the home care company.
Because home care personnel must be available 24
hours per day, on-call related activity may be required.
Depending on the organization and workload activities,
afternoon, evening, or weekend shifts may be used.

CTI~ITI~S
OF THE HOM
Activities vary greatly, depending on the services provided and the size of the operation. In small offices, the
pharmacist may wear many different hats. In large offices,
the pharmacist may do only one task on a given day.

Table I

Home care preadmission criteria

Patientlcaregiver agrees to receive services in the home.

Patientlcaregiver are willing to learn the necessary steps to
administer their drug(s) in the home.
4
The home environment is acceptable (clean, access to telephone and running water).
0
The patient is readily accessible to the home care provider.
* The patient has adequate family support, both physically and
psychologically.
4
A physician is readily available in the event of an emergency,
ongoing clinical updates, and/or order changes.
* The medication ordered is appropriate to be given in the
home environment.
* The indication, dosage, and route of administration of the
medication(s) ordered is appropriate.
e Labs etc., are ordered to access the effectiveness of the therapy ordered.

Table 2 Home care patient database

4

*
4
0

*
*

*
e

*
*
*
*

Patients name, address, phone number, date of birth.

Alternate contact information in the event of an emergency.
Information on the status of any advance directive.
Height, weight, gender.
Diagnoses.
Location and type of intravenous access and date of
placement.
Pertinent laboratory test results.
Pertinent medical history and physical findings.
Accurate history of allergies.
A detailed medication profile, including all prescription and
nonprescription medications, home remedies, and investigational and nontraditional therapies.
Other agencies involved in patient care.
Prescribers name, address, phone number, etc.
A plan of care.
Patient education activities.
Anj7 functional limitations.
Any pertinent social history.

Tasks include dispensing-related functions; technician

oversight; obtaining orders from physicians and then assessing the orders for appropriateness; assessing the patient and caregiver for the appropriateness of providing
care in the home; patient and/or caregiver education;
providing education for nursing agencies, discharge planners, etc; answering drug information questions; sales
support; and so on. No one day is ever the same. The following explains these activities in greater detail.
One of the primary roles of the pharmacist is the preadmission assessment. This role ensures that each patient
is assessed for appropriateness using predetermined admission criteria. Common criteria are outlined in Table 1.
In conjunction with other members of the home care
team and with the patients physician, a decision is made
to either accept the patient for home care services or refer
them back to the hospital discharge planner or referral
source. Once accepted, an assessment is completed and an
initial patient database established. Table 2 lists some
of the items that are part of this database. Again, the
pharmacist is an integral part of this process. Much of this
information is obtained via the telephone in conversations
with the physician, hospital personnel, or patient. Information may also be received via fax or from the home
care agency nurse. Pharmacists working in a hospitalbased home care pharmacy may be able to go up to the
floor and obtain this information directly from the medical record, floor nurse, and/or patient.
One of the documents that is part of this patient database is the care plan or plan or care. The plan of care
should indicate the treatment goals and indicators of de-

ome Care, Clinical Pharmacy Careers in

sired outcomes. any interventions that need to be done,

and the frequency of those interventions. Any drug-related problems that occur or have the potential to occur
should be addressed by the pharmacist, along with other
members of the patient care team. When multiple providers are involved with the patient, the pharmacist is in
an ideal position to coordinate the information flow and
care of the patient.
The plan of care should be developed initially and
updated as needed. Based on the drug(s) used and the
potential for side effects and adverse drug reactions, the
pharmacist should determine what type of monitoring
is needed (e.g., labs, physical findings) and the frequency at which it is to occur. The pharmacist must communicate this plan to others involved and provide updates
as needed.
Another role of the pharmacist is the selection of products, infusion devices (i.e., pump), and ancillary supplies. Many factors need to be considered when choosing
the administration method, infusion device to use, and
what ancillary supplies are needed.
The stability, compatibility of the drug, and volume
of the drug are important considerations when determining what method (IVPB, IV push, continuous infusion)
or infusion device (elastomeric, electronic infusion device, etc.) will be used. Nursing agency knowledge and
ability of the patient to learn the methodology are all
important considerations. Patient convenience, prescriber preference, and cost must also be considered. Again,
the pharmacist is able to weigh the pros and cons of
any method and help the patient care team make appropriate decisions.
The ongoing clinical monitoring is the hallmark of the
pharmacists involvement. By having regular, ongoing
conversations with the patientharegiver, physician, and
home care nurse, the pharmacist is able to make an ob-

Table 3 Education-related issues

0

e
0
0

Medication related, including dose, route of administration,

dosage interval, duration, side effects, adverse reactions (and
their management).
Proper aseptic technique.
Precautions and directions for administering the medication.
Equipment use, maintenance, and troubleshooting techniques.
Proper care of the vascular access device and site (if applicable).
Home inventory management, how to contact help, emergency issues (what to do if something goes wrong).
Special precautions and directions for the preparation,
storage, handling, and disposal of drugs, supplies. and
biomedical waste.

437

jective evaluation of the therapy(ies), make appropriate

recommendations for changes, and effectively communicate those changes to the patient/caregiver and all involved health care providers.
On an initial and ongoing basis, the pharmacist
should be providing education to the patient and/or caregiver. Some of this information may be provided verbally, although most is provided in writing. Table 3 lists
some of these education-related issues. The pharmacist
should be involved in the development of all educational material.

s
The range of careers is very diverse. Pharmacists may
choose to remain clinically focused, providing hands-on
care to the patient. Opportunities exist to do research on
the delivery and use of drugs in the home environment.
Extended stability studies are one area where the pharmacist can become involved. If the pharmacist gets involved in clinical research, they should ensure that all
appropriate policies and procedures are followed, that the
patient and health care providers have appropriate information concerning the drug(s), and that all required
record-keeping requirements are met.
Many sites offer clinical clerkships for undergraduate
pharmacy students and several post-PharmD residencies
in home care exist.
From an operational perspective, pharmacists who
have a business background can progress from a stafflevel position to branch, regional, or corporate management positions. It is not unusual for a mid- to high-level
manager to have started out as a staff pharmacist.
The pharmacist should be actively involved in the
organizations performance improvement activities.] ASpects of care that can be monitored include, but are not
limited to, patient satisfaction, unscheduled admissions,
medication errors, adverse drug reactions, infection control-related issues (e.g., line infections), unscheduled deliveries, and so on.
The pharmacist must also take an active role in the
development, implementation, and review of an organizations policies, procedures, and protocols. The pharmacist should ensure that all aspects of care are addressed,
including patient care, drug preparation and dispensing,
quality control, infection control, and equipment maintenance. Involvement in such activities can have farreaching effects on efficiency and financial outcomes.
As a manager, the pharmacists responsibilities include: 1) setting the goals (both short- and long-term) of
the pharmacy, based on the needs of the patients and

438

mission/goals of the organization; 2) developing plans to

achieve those goals; 3) implementing those plans; 4) assessing whether the goals are being met; and 5) instituting
corrective actions when necessary.
The pharmacy manager will have multiple areas of
responsibility, such as managing the pharmacy (including compliance with laws, regulations, and accreditation
standards), financial resources (drugs, budgets, reimbursement), and pharmaceutical care and human resources (scheduling, hiring, education and training, staffing needs).
Pharmacists that have a sales/marketing nature can
pursue this career tract if so desired. As mentioned prcviously, positions range from branch salcdmarketing to
corporatewide strategic sales management.

ome Care, Clinical Pharmacy Careers in

to providc sound pharmaceutical care to the patients

receiving home care services.

1.

2.

3.

4.

5.
The practice of pharmacy in the home care environment
presents many opportunities for professional and personal
growth. T h c practice continues to evolve and will
continue to offer pharmacists multiple opportunities (both
clinically and management related), as well as continuing

6.

I.
8.

American Society of Health-System Pharmacists. ASHP

guidclines on minimum standards for home care pharmacies. Am. J. Health-Syst. Pharm. 1999, 56, 629 638.
American Society of Health-System Pharmacists. ASHP
guidelines on the pharmacist's role i n homc care. Am. J.
Health-Syst. Pharm. 2
National Home Infusion Association. White Paper: Home
ln/usion Servicrs, Payineizt Modes und Operutionnl Costs;
www.nhianet.org.
National Home Inruusion Association. Resourcrs ,for
Priyc,r:r, Physiciatzs & Providers: Overview of' Home
h@sion Therapy; www.nhianet.org.
National Home Infusion Association. Resources ,firr
.ricians & Providers: Patient Care Process in
on Thcrupy; www.nhianet.org.
www.nhianet.org.
www.ashp.org.
Winiarski, D. Performance improvement in action: Kecliveries of iiilusion supplies. Infu-

PHARMACY PRACTICE ISSUES

Ana Clopes
Hospital de la Sta. Creu i Sant Pau, Barcelona, Spain

The introduction of home care is unavoidably bound to

the changes that have been taking place in most health
systems over the last 30 years. The financial pressure to
reduce the hospital length of stay has a direct relationship on the acceptance of home care, and on the
growth of other activities such as nursing homes and
outpatient clinics.
Home care or hospital at home is defined as a service
that provides active treatment by healthcare professionals
in the patients home of a condition that otherwise would
require acute hospital in-patient care, always for a limited
time period.[
This definition is the same for all models of health
systems but the application and focus of care differ.
However, in most systems home care implies the application of high technology in the patients home for a
limited period, rather than care for chronic patients. For
this reason, in most systems, the referral centers are
the hospitals.
The concept of home care originated in the university
hospitals in the forties. In 1947 the Montefiori Hospital in
New York planned to extend the hospital to the patients
home. But home care was in fact first applied in the
sixties with Hospitalisation a Domicile in France in
1961.[21It has been implemented in a number of other
countries, including the United States,[31Canada, and the
Netherlands.14] Home care coverage within the Medicare
program in the United States was implemented in 1966.
The acceptance of home care has been faster in North
America than in European countries where there is no
direct cost to the patient or an insurer when a patient is
admitted to a hospital.[51

to different ~tudies][,~-*~
without loss of effectiveness
of treatment. A meta-analysis carried out by Hughes
et
studied the impact of home care hospital days
(22 studies) and demonstrated a significant reduction
in hospitalization days across studies due to home
care, with a cumulative effect size of -0.38 (CI,
-0.42 to -0.34, p=O.OOl).
The patients maintenance in hidher family environment. This implies an improvement in the quality of
life] and patient satisfaction. I
The patients involvement in hisher own care. This is
not typical in conventional health care and should be
considered to improve the effectiveness of treatment.
At the same time it breaks the bonds of nonpositive
dependence that sometimes exist between the patient
and the hospital.
Avoidance of the risk of nosocomial infections. Patient
care in a nonhospital environment avoids contact with
hospital organisms, which are usually more resistant to
antibiotic treatment.
Development of health models which integrate the
different areas (basically hospital and communi9
cave). The separation between the different areas of
patient care is artificial, while integration implies a
higher quality and more individualized care.

The way home care is organized depends more on the

type of care within each country than on the kind of
care provided. Home care can be classified according
to the type of reference center or according to the type
of structure.

Reference Center
The advantages of home care are:
0

Reduction in hospital length of stay.[llThis is reflected

in the decrease in costs [from 30 to 85% according

Encylopedia of Clinical Pharmacy

DOI: 10.1081E-ECP 120006376
Copyright C 2003 by Marcel Dekker, Inc. All rights reserved.

Hospital-based home care sewices

The hospital is responsible for the patients and is the
decision-making center. A hospital team organizes,
439

440

stimulates, and assumes the leadership of the inclusion

of patients in home care. High technology such as longterm ventilation,"21 intravenous antibiotics administration,[13] chemotherapy admini~tration,"~]or parenteral
nutrition"'] is included. The length of hospital stay is
reduced by early discharge of patients following
elective surgery with a home-based rehabilitation program,[1~19~

Community-based home care services

These usually include patients with chronic diseases requiring low technology. The community center medical
team visits the patient at home. Examples of programs
applying such schemes are home care programs for
diabetes, hypertension, terminally ill patients, physiotherapy at home, and care of elderly.
Programs may also consist of mixed care with
collaboration between the different areas of the health

~ l a s s ~ f ~ c a tAcc~rdin
ion
Type of ~tructure
External provider. The health care team (physicians,
nurses, and pharmacists) and the drugs and ancillary
supplies proceed from a commercial provider who has
a contract with hospital or the reference center.
A mixed structure of external provider and the reference
center. The hospital may provide the medical team and
pharmacy services, for example, and the external provider supplies the nurses and drugs.
Reference center structure. The physicians, nurses and
the pharmacy services depend on the reference center,
hospital or community centers.

Selection Criteria
Selection criteria for patients who are candidates for
home care are adapted to each environment, geographical area, and type of patient. These criteria can be
divided into medical condition and psychosocial and
family support. They will be described in each protocol
of patients' inclusion defined for each diagnosis. But
some general environments should be evaluated in all
cases: home and family environment.

Home Care Pharmacy Practice (Spain)

Home environment
A series of home requirements must be met and in all
cases assessment of the following is needed:

* Geographic access to the reference center that each

home care team will define according to the characteristics of the area.
8
A telephone is imperative for continued contact between the patient and the home care team.
* The home should be clean and have electricity and
running water. Based on this information, the pharmacist, in conjunction with the other team members,
will assess the patient's appropriateness. Other requirements such as a refrigerator will also be necessary
in some cases if the patient requires medication that
has to be stored at low temperatures.

Family environment
The presence of a caregiver is mandatory in most of the
home care protocols, although this will depend on the
therapy administered and also on the medical situation.
The home care team should assess the patient's or
caregiver's capacity to be involved in the care.

Patient's Origin
Patients evaluated for inclusion in a home care program
may proceed to a hospital, emergency room, or community care center.

Procedure for the Patient's Admission

The whole home care team is involved in patient inclusion
and care planning although each member will play a
specific role in the activities.
The steps in the admission procedure are:

1. The physician in charge of the patient considers

whether helshe will be a candidate for home care
according to the clinical assessment described in
the previously defined protocol. In the detection of
patient candidates, the pharmacist and the nurse
who are working in the home care team can also
participate.
2. Family support and home environment are evaluated by the social worker or by the nurse together
with the pharmacist, also according to the
previously defined protocols.
3. The entire home care team plans the care.

441

Home Care Pharmacy Practice (Spain)

Table 1 Infections most frequently included in home

care programs
Skin and soft-tissue infections
Cellulitis
Abscess
Postoperative wound infection
Posttrauma wound infection
Diabetic foot
Decubitus ulcer
Bone and joint infections
Acute and chronic osteomyelitis
Septic arthritishursitis
Prosthetic joint infections
IV line infection
Infective endocarditis
Ear and sinus infections (sinusitis/otitis/mastoiditis)
Acute exacerbation of pulmonary symptoms in cystic fibrosis
Lung infection (hospital- or community-acquired pneumonia)
Gastrointestinal infections (abscesdperitonitis)
Kidney, bladder, and prostate infections (pyelonephritis/
perinephric abscess)
Systemic febrile syndromes
Cytomegalovirus infection
Febrile neutropenia
Brain abscess

The patient or the caregiver is trained in and

informed about the therapy to be carried out in the
home. The information has to be oral and in writing
and the pharmacist and the nurse can provide it.
The patient goes home and therapy begins.

One option to facilitate the coordination among the different steps is periodic meetings to discuss the cases with
the participation of all the members of the home care team.

F ~NTERVEN~IO~S
Home Parenteral Antibiotics
In general, all types of infection and all organisms are
susceptible to home IV antibiotic therapy. The treatment
of patients with bone and joint infections has proven
highly effective and is now well accepted.[211Other bacterial infections that have been studied extensively are
skin and soft tissue infections and lung infections. The
reason is that these infections fulfill two important
criteria: patients are clinically stable and require prolonged IV antibiotic therapy (>7 days).[221But home care
can be extended to great number of infections: bacterial,
viral, and fungal (Table 1). The patient's admission to
home care should be considered from the beginning of the
infection or should be wait until the patient is clinically
stable, depending on the infection.
A large number of cost-effectiveness studies have been
carried out (Table 2), all with positive results.

The maintenance therapies of opportunistic disease in

acquired immune deficiency syndrome (AIDS) are an-

Table 2 Studies of cost savings from home IV antibiotic therap)

study

Antoniskis A 1978[3s1
Stiver 1978[391
Kind 1979'401
Swenson 1981["I

20
23
15
8

Poretz 1982[421
Stiver 1982[431
Rehm 1983["]
Kind 1985[451
Corby 1986[")
Chamberlain 1988["'
Kane 1988[4s1
Tice 1991[491
Williams 1993'501
Williams 1994"']
Clopes 1998[291

150
95
48
315
36
6
27
290
56
58
13

Infection
NA
NA
NA
Osteomyelitis, pyelonephritis
and others
Osteomyelitis
NA
Bone and joint infections
NA
NA
Osteomyelitis
Cystic fibrosis
Osteomyelitis
Cellulitis. osteomyelitis
and others
Pneumonia
Several

Average savingsldayl
patient ($)

Average savingsldayl
patient (Euros)

165
97
95
148

196
115
113
176

142
135
305
350
345
265
618
303
262

169
160
362
416
410
316
735
360
3 12

252
152

300
180

Home Care Pharmacy Practice (Spain)

442

Table 3 Opportunistic disease in AIDS candidates for

home care
Infection
Cytomegalovirus infection

Acyclovir-resistant
Herpes simplex
Acyclovir-resistant
Herpes zoster
Pneumocystis carinii
pneumonia
Cryptococcosis
Histoplasmosis
Coccidiomycosis
Drug-resistant
mycobacterium
Pneumonia

Antimicrobial therapy
Maintenance and
induction therapies:
Ganciclovir IV
Foscarnet
Cidofovir
Foscarnet
Foscarnet
Pentamidine IV
Pentamidine aerosol
Amphotericin B
Amphotericin B
Amphotericin B
Amikacin

givers receiving hospital-at-home care reported greater

satisfaction than those in the hospital group.
One of the fundamental pharmacological treatments in
this group of patients is the opioid continuous infusion
with devices adapted to outpatient treatments as patientcontrolled analgesia pump.

The administration of chemotherapy at home has demonstrated that it is feasible and that it produces a decrease of
adverse effects and an improvement of the quality of life
and a monetary savings.i251
However, home care can also give support to the
patient with cancer in other areas: parenteral antibiotics
in febrile neutropenia, nutrition and fluid support, or
pain support.

3rd Generation Cephalosporins

Aminoglycosides

tibiotic therapy candidates for home care. The reasons are

that the patient is clinically stable and requires long-term
therapy. In some cases the induction can also be
considered to be treated at home. These infections and
treatments are described in Table 3.
Other support therapies for AIDS patients that can be
given at home are nutrition support, parenteral and
enteral, IV immunoglobulins, chemotherapy in lymphoma
or Kaposi's sarcoma, and care of terminally ill patients.

ystic Fibrosis
The majority of antibiotics needed for the treatment of
infectious complications of cystic fibrosis have to be
administered intravenously for several weeks; until recently these treatments were given on an in-patient basis.
As the lung disease progresses, patients may require more
frequent hospitalizations. This greatly increases health
care costs and adversely affects the patient's quality of
Home intravenous therapy in cystic fibrosis may also
cut costs by avoiding hospital admissions and may
improve family life and psychological well-being.

alliative Care
Some trials have evaluated the effectiveness of hospital at
home for terminally ill patient^.'^''^^] Patients and care-

In the support of hematology patients, the therapy candidates for home care may be chemotherapy, IV antibiotics in febrile neutropenia, blood products, IV immunoglobulins, fluid/electrolyte replacement, central line
maintenance, and specific treatments such as deferoxamine administration.
In the support of hematopoietic stem cell transplantation
there are programs developed to permit treatment with
chemotherapy at home and treatment of complications.[261

In cardiology patients some home-based interventions

have been published on the treatment of heart failure
patients and heart transplant patients. In our center
we also have experience with patients with pulmonary hypertension.
Increased survival of cardiovascular disease has resulted in a significant rise in the number of patients with
chronic, refractory heart failure requiring intensive medical management and follow-up. In a controlled
among a cohort of high-risk patients with congestive heart
failure, beneficial effects of a postdischarge home-based
intervention were sustained for at least 18 months, with a
significant reduction in unplanned readmissions, total
hospital stay. hospital-based costs, and mortality.
Cardiac patients receiving inotropic therapy can be
successfully treated in the home using specific admission
criteria and monitoring guidelines,'2s1 and home dobutamine infusions can improve functional status and quality
of life of patients with severe heart failure.

Home Care Pharmacy Practice (Spain)

Home care can also give support to heart transplant

patients. In our center we have the experience of a
program for organ rejection therapy, antilymphocyte
immunoglobulin, and high dosage of methylprednisolone
at home. After the experience, we can say that it is
feasible to carry out this treatment at home and the
satisfaction of the patients is high.[291
There are experiences of ambulatory treatment of
patients with pulmonary hypertension, with inhaled nitric
oxide and with prostaglandins, in both cases using an
ambulatory delivery system. In our center we have an
outpatient treatment program of pulmonary hypertension
with inhaled iloprost leading in some patients to
significant improvement in pulmonary hypertension and
in the quality of life with no adverse effects.

Nutrition

or%

The candidates for home nutrition support should be

clinically stable patients that require enteral or parenteral
nutrition for a long term. Before initiation of home
nutrition support, a nutrition assessment and a care plan
should be performed and after initiation nutrition status
should be monitored on a regular basis.[301
The indications included in a study of incidence of
home nutrition support made by the American Society for
Parenteral and Enteral Nutrition were:
Pareteral nutrition:
0
Short bowel disease.
e
Crohns disease and ulcerative colitis.
m
Gastric or duodenal fistula.
.S
Radiotherapy damage.
e
Congenital disorders.
e
Disorder of the GI motility.
Enteral nutrition:
0
Neuromuscular diseases:
Amyotrophic lateral sclerosis
Myasthenia gravis
Parkinsons disease
Alzheimers disease
Cerebral palsy
Cerebral vascular accident
Brain tumors
9
Oral and GI diseases:
Secondary to surgical procedure:
Head and neck
Esophagus or stomach
Malabsorption
Disorder of GI motility
Crohns disease and ulcerative colitis

443

Home care in elderly patients can help with the geriatric

assessment of disability and functional status and the
prevention of complications related or not related to
drugs. Stuck et al. conducted a three-year, randomized,
controlled trial of the effect of annual in-home comprehensive geriatric assessment and follow-up for people
who were 75 years of age or older.[311The results showed
that this intervention can delay the development of disability and can reduce permanent nursing home stays
among elderly people living at home.

Some programs of home care have been applied to

pediatric patients. Home care for cystic fibrosis and oncology patients is previously described. Other examples of
home care programs in children are patients with asthma
that require high technology at home,r321children with
newly diagnosed diabetes,[331and infants who require
neonatal special care and a family support program.[341

ery an

etrk

ts

Because of developments in surgery, early discharge after

surgery is becoming popular. These programs sometimes
need support at home, for example, with rehabilitation.[35.361In obstetric patients there have been experiences of home care giving support to the woman before or
after childbirth.[371

ers
Other home care programs with smaller pharmacist
implications are long-term mechanical ventilation and
renal dialysis.

The pharmacists role in home care should include the

following functions:
Development of protocols or practice guidelines for
each diagnosis candidate for inclusion in the home
care program in collaboration with other home care
team members.
Preadmission assessment. The pharmacist. together with the other team members, should assess

444

Home Care Pharmacy Practice (Spain)

3.

4.

5.

6.

the patients suitability for home care on the basis

of criteria described in the protocol (home
environment, psychosocial factors, and clinical
condition).
Coordination of preparation and delivery of drugs
to the patient or caregiver. Together with the medication, the pharmacist should provide the ancillary supplies and drug delivery systems. The pharmacist should also ensure appropriate disposal of
cytotoxic products.
Planning home treatment and care, also with an
interdisciplinary approach, involving the patient
and in collaboration with other team members. This
home treatment and care plan should be reviewed
and updated periodically and outcome should be
assessed.
Therapy monitoring using parameters previously
defined in the protocol. The pharmacist should carry
out this monitoring from the medical records and
verbal exchange with the patient and/or the caregiver, nurse, physician, and other family members.
Patient and caregiver education about the treatment.
The information should be both oral and written and
include:
e

Description of the therapy (drug, dose, route

of administration).
Goal of the therapy.
Administration technique.
Special precautions regarding storage, handling, and disposal of drugs.
Emergency procedure.

11. Participation in performance improvement activities. Patient satisfaction and outcome should be
monitored to detect and resolve problems. Quality
of life should also be considered.

news/newslettershomecare/index.html.
e

7. Information for home care team members regarding:

Drug stability and compatibility.

Adverse effects.
Administration technique.

8. Early detection and reporting of adverse drug

effects.
9. Monitoring pharmacokinetic laboratory data for
evaluation of efficacy and prevention of adverse
effects of the specific drugs (vancomicyn, aminoglycosides, cyclosporin, etc.).
10. Selection of drug delivery systems for parenteral
and inhaled drugs. This selection should be carried
out in cooperation with the physician and nurse
taking into account safety features, ease in handling, and cost. It should be individualized according to the patients characteristics.

Section of Home Care Practitioners of American

Society of Health-System Pharmacists (ASHP)(USA):
www. ashp.orghomecare.
Home Care Highlights of American Society of HealthSystem Pharmacists (USA): www.ashp.org/public/
ASHP Guidelines (USA): www.ashp.org/bestpractices.
American Society of Parenteral and Enteral Nutrition
(with the Standards of Practice for Home Nutrition
Support)(USA) : www. clinnutr .org .
Joint Comission on Accreditation of Healthcare Organizations (USA): www.jcaho.org.
American Academy of Hospice and Palliative Medicina (USA): www.aahpm.org.
Edmonton Palliative Care Program (Canada): www.
palliative.org.
National Council for Hospice and Specialist Palliative
Care Services (United Kingdom): www.hospice-spccouncil,org.uk.
Agence Nationale dAccreditation dEvaluation en
Sante, France (with the recommendations for the
medical records of the home care patients for ambulatory nursing professionals) (France): www.anaes.fr.
American College of Chest Physicians (ACCP) (Patient
Education Guides: Mechanical Ventilation at Home)
(USA): www.chestnet.org/health.science.policy.

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2. Morris, D.E. Sante Service Bayonne: A French approach to
home care. Age Ageing 1983, 12, 323-328.
3. Frasca, C.: Christy, M.W. Assuring continuity of care
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Bull. 1986, 12. 167-171.
4. Bosna, E. KITTZ: Innovation in Home Care. In Capital
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Darlow. M.A.; Pounsford, J. Hospital at home or acute
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~

51.

PHARMACY PRACTICE ISSUES

Arthur C. Lipman
University of Utah, Salt Lake City, Utah, U.S.A.

Hospice programs have existed in the United States for

more than 25 years, providing symptom control-based
palliative care for patients with advanced, life-limiting
disease. In fact, more than 3000 hospice programs are
now operating or are in formation in the United States.
The World Health Organization (WHO) defines and
comments on palliative care as follows: Palliative care
is active total care of patients whose disease is not responsive to curative treatment. Control of pain, of other
symptoms, and of psychological, social and spiritual
problems is paramount. The goal of palliative care is
achievement of the best possible quality of life for patients and their families.[11 Pharmacists often serve as
key members of hospice interdisciplinary teams. and
many opportunities for pharmacists to provide valuable
clinical services exist in hospice programs. Most hospice
care is provided in the patients homes. Palliative care
units are increasingly being integrated into hospitals and
long-term care facilities.

The explosive growth of interdisciplinary hospice and

palliative care programs for patients with terminal
illnesses has created excellent opportunities for pharmaceutical care. In the United States, the number of
hospice programs has grown from 1 less than 30 years
ago to approximately 3000 today. The importance of
pharmacists providing care to terminally ill patients
appeared in the American pharmaceutical literature over
25 years ago.[21In addition, rapidly expanding opportunities for pharmacists in hospice care were defined in the
1 9 9 0 ~ . [ All
~ pharmacists should know about the availability and quality of hospice care in their communities,
and should be able to refer patients to programs appropriate for their needs.
In the 1970s and 1980s, hospices provided care
primarily for patients with advanced cancer. Today,
hospice care is common for patients with cancer; acquired
Encyclopedia of Clinical Pharmacy
DOI: 10.1081E-ECP 120006340
Copyright 0 2003 by Marcel Dekker, Inc. All rights reserved

immunodeficiency syndrome (AIDS); degenerative neurological diseases, such as multiple sclerosis and amyotrophic lateral sclerosis; end-stage organ system failure,
including congestive heart failure, hepatic disease, pulmonary disease, and renal disease; and patients with dementia and other progressive, irreversible disorders.
The word hospice is derived from a medieval
French term for resting places established for Crusaders
on their journeys to the Holy Land. It was revived in the
last century by a Catholic order that provided resting
places for terminally ill patients in Ireland and England.
By the mid-l900s, several such hospice programs existed
in the United Kingdom. However, the modern hospice
movement based on comprehensive symptom control only
began in 1967, with the opening of St. Christophers
Hospice in London. The first American hospiceoriginally called simply Hospice, Inc., now The Connecticut Hospice-was
started in the early 1970s in New
Haven, CT. That program became the National Cancer
Institute Demonstration Project of Hospice Care from
1974 to 1977. More than 1000 American pharmacists are
now estimated to provide hospice pharmaceutical care as
integral parts of their practices. Many more are needed.
A hospice is a program of care, not necessarily a
facility, per se. In the United States, most hospice care is
provided in patients homes. Some dedicated inpatient
hospice facilities exist, as do hospice wings of long-term
care facilities and hospice beds in hospitals. These
inpatient hospices commonly provide support for the
home care programs, respite care (admission of patients
to allow their families to rest so that they can resume
home care), admissions for difficult symptom control
problems, and admissions for care in the last hours or
days, when necessary.
The term palliative care was used initially to define
the provision of symptom relief for patients who were no
longer considered to be candidates for cure or remission.
Today, the need for palliative care throughout the course
of life-threatening disease, including patients for whom
cure will be achieved, is becoming more widely accepted.
Palliative medicine is a recognized medical specialty in
the United Kingdom and several other countries. In 1997,
447

448

Hospice and Palliative Care

the report of the Committee on Care at the End of Life of

the Institute of Medicine of the National Academy of
Sciences concluded that palliative care should become,
if not a medical specialty, at least a defined area of
expertise, education and research. [41 Hospice and
palliative care are often used interchangeably.
Hospices provide care for patients with advanced,
irreversible disease and a life expectancy measurable in
weeks to months as opposed to years. The defined unit of
care is the patient and their family. The focus of care
spans physical, psychological, social, and spiritual domains. This requires an interdisciplinary team. Nurses
usually coordinate home visits and serve as team leaders.
The patients primary care physician normally continues
to provide care, often in consultation with the hospice
medical director. Other key members of the team are

social workers, nursing assistantslhome health aides,

chaplains, volunteers, and pharmacists. Persons from several other disciplines support the hospice team (Fig. 1).
As shown in Fig. 1, the central focus of care is the
patient, family, and primary care person(s), who is usually
a family member. They continue to work with their
primary physician. The interdisciplinary hospice team
listed in the next concentric circle from the center provides direct support. This team may include both health
care professionals and other persons who are equipped to
deal with issues that are complicating the lives of the
patientdfamilies (e.g., financial counselors). The third
concentric circle from the center includes persons who
support the team. Pharmacists have both direct patient
care and supportive roles in hospice teams as described in
the following paragraphs.

PATI ENT/FAM ILY

SUPPORT SYSTEM
PUBLIC INFORMAT ION

Fig. 1 The hospice interdisciplinary team. The patient, primary caregiver, and family are the focus of the hospice teams efforts in
collaboration with the patients primary physician. The core team is represented by the next circle away from the center. The support
team is indicated by the outer circle. Community resources that support hospice care are listed outside that circle. Pharmacists serve on
both the core team (second circle from the center) by providing direct pharmaceutical care to patients and families, and on the support
level (next circle out from the center) by providing professional and public education about drug therapy in the care of terminally ill
patients. (From Lipman AG, Berry JI. Pharmaceutical care of terminally ill patients. Journal ofPharmaceuticaZ Care Pain and Symptom
Control, 1996; 3(2):31-56.)

Hospice and Palliative Care

There is a need for elimination of artificial barriers

between the time when a cure is sought and the
inevitability of death is accepted. This barrier exists, at
least in part, due to the requirement for documenting life
expectancy by the Medicare Hospice Benefit. The U.S.
Congress defined this benefit in the 1980s through which
Medicare beneficiaries can assign their medicare part B
benefits to any Medicare-certified hospice program. That
program then receives a daily fee from Medicare in return
for assuming responsibility for the patients total care,
including drugs and pharmaceutical care. To be eligible
for this benefit, the patients physician must certify a
probable life expectancy of 6 months or less. This arbitrary
time limit has created psychological barriers for physicians, patients, and their families, resulting in many patients not being referred, seeking, or receiving the hospice
care to which they are entitled. Because pharmacists commonly have long-standing relationships with families they
serve and enjoy their patients trust, pharmacists are often
in the best position to advise patients about the importance
of developing relationships with a hospice program as
soon as possible after determination that the disease has
a probability of being life ending.
Hospice and palliative care are becoming much more
widely recognized by healthcare providers. The American
Academy of Hospice and Palliative Medicine (founded in
1988 as the Academy of Hospice Physicians) and the
Association of Hospice Nurses are respected national
organizations of health care professionals who provide
palliative care. The National Hospice and Palliative Care
Organization (NHPCO, formerly known as the National
Hospice Organization [NHO]) includes the National
Council of Hospice Professionals (NCHP). The 15 membership sections of the NCHP include an active pharmacist section.

449

often in an excellent position to recommend hospice care

and to refer families to appropriate programs.
Services provided by pharmacists in American hospices have only been qualitatively and quantitatively
documented twice, in 1979r51and 1991.[61Many more
pharmacists provide these services today than when the
latter survey was completed, but the observed types and
mix of services do not appear to have changed much since
the 1990s.
Although many pharmacists serve as hospice volunteers, about three-fourths are paid for their services. The
majority of pharmacists who provide services to hospice
programs are not employed directly by the hospices, but
by a provider of pharmaceutical services such as a home
health pharmacy or hospital. Many are employees of
pharmacies that have contracts with hospices to provide
drugs and services. In recent years, specialized hospice
pharmacy service providers have been developed in
several parts of the United States.
The 1991 surveyL6 reported that dispensing fees
accounted for about one-half of the reimbursement
received by pharmacists. In the past few years, payment
for cognitive services has become more common. Some
pharmacists provide only consulting or dispensing services, but many provide drug products, home health
supplies and equipment, and pharmaceutical care. Pharmaceutical services other than prescription dispensing
services are not usually required by licensing or certifying agencies. Payment for cognitive services is at
the discretion of the hospice administration. The experience of many hospices has been that integration of
pharmacists directly into planning and provision of patient care both improves the quality of symptom control
and lowers costs. In many hospices, pharmacists are now
active participants in weekly or biweekly interdisciplinary team (IDT) meetings at which patients progress is
discussed and care plans are refined.

UTI

It is unfortunate that many physicians and families remain

unaware of the benefits that modern hospice care
provides. As a result, referrals to hospice programs often
do not occur, or occur when the patient has only days to
live. Hospice care is most efficacious and cost effective
when referrals are made early, while the patient still has
months to live and is reasonably active. Relationships
between the hospice team and the patient/family that are
established before crises occur are most effective. Such
relatively early relationships permit the hospice team to
provide more effective and efficient care when it is
actively needed. As the most accessible and trusted
healthcare professionals (Gallup surveys), pharmacists are

H
Most pharmacists possess many of the skills needed to
provide pharmaceutical care to terminally ill patients. In
the last few years, pharmacy curricula have placed increased emphasis on pain management and symptom
control.
Many pharmacists increase their knowledge of drugs
and dosing regimens for symptom control in seriously ill
patients through consultation and visits with experienced
hospice pharmacists. Pharmacists can gain a valuable
perspective on hospice care by taking hospice volunteer
training. Continuing pharmaceutical education directly

450

Hospice and Palliative Care

Table 1 Selected palliative care resources

Journals
Journal of Pain and Palliative Care Pharmacotherapy (incorporating the former Journal of Pharmaceutical Care in Pain and Symptom
Control and The Hospice Journal)
Pharmaceutical Products Press, an imprint of The Haworth Press, 10 Alice Street, Binghamton, New York; (800) HAWORTH;
e-mail: [email protected]
Journal of Pain and Synzptom Management
Elsevier Science, Inc.; (888) 437-4636
Pain
Journal of the International Association for the Study of Pain (IASP); (206) 547-6409
The Journal of Pain
Official Journal of the American Pain Society; (800) 654-2452; e-mail: [email protected]

Newsletters
IASP (International Association for the Study of Pain) Newsletter
(206) 547-6409
American Pain Society Bulletin
American Pain Society; (847) 375-4715; e-mail: [email protected]

Texts
Berger AM. Portenoy RK, Weissman DE. Principles and Practice of Supportive Oncology. Philadelphia, Lippincott-Raven, 1998.
Doyle D, Hanks GWC, MacDonald N, editors. Oxford Textbook of Palliative Medicine, 2nd edition. New York and Oxford,
Oxford University Press, 1997. Berger AM, Portenoy RK, Weissman DE. Principles and Practice of Supportive Oizcology, 2nd Ed.;
Philadelphia, Lippincott-Raven. in press 2002.
Web sites
National Hospice and Palliative Care Organization
www.nho.org
PDQ (Physician Data Query)

[email protected]/
Talarian Map Cancer Pain
www stat.washington.edulTALARIAiTALARIA.htm1
Open Society Institute: Project Death in America

www.cyberspy.com/-websterldeath.htm1
The Palliative Medicine Program
www.mcw.edu/pallmed
Hospice Foundation of America
www.hospice foundation.org
Information about hopsice with links
www.hopsiceweb.com
Hospice Hands web site
http://hospice-cares.com
Purdue Pharma Pain and Palliative Care Information
http://www .partnersagainstpain.com
Additional web references can be found in Ref. [9].

451

Hospice and Palliative Care

relevant to hospice care and symptom control is often

provided at meetings of the American Society of Consultant Pharmacists, American Society of Health-System
(previously Hospital) Pharmacists, American Pharmaceutical Association, the National Hospice and Palliative
Care Organization, and at some state and local professional associations. Several journals, newsletters, and web
sites focus on pain and symptom control. Examples are
listed in Table 1. Because hospice care is interdisciplinary
by definition, most programs are open to suggestions of
additional ways in which any discipline can contribute to
the programs overall objectives.
Hospice programs are always recruiting and training
new volunteers. Therefore, most readily welcome calls
from persons in the community interested in learning
more about the program or becoming involved in patient
care. Any pharmacist can simply call a local hospice and
make an appointment to meet with the staff to discuss
unmet pharmaceutical care needs. These include a range
of activities, including administrative responsibilities,
provision of medications, and outcome-oriented pharmaceutical care.
Common administrative functions include the following:
Managing program or facility (if applicable)
Serving on the hospice board or professional advisory
committee
Negotiating contracts with provider pharmacies
Reviewing and ensuring compliance with state and
federal laws and regulations that relate to the provision
of hospice pharmaceutical care and services
Developing drug-related policies and procedures
Participating in continuous quality improvement and
quality assurance activities, including drug-use evaluations and cost-avoidance and cost-effectiveness
studies
Procuring medications for indigent patients through
pharmaceutical industry patient assistance programs
Managing the hospice formulary
Common clinical functions include the following:
Developing pharmaceutical care plans, including
assessment and monitoring for therapeutic and toxic
outcomes
Participating in hospice interdisciplinary team meetings (chart sounds)
Performing drug regimen reviews
Providing pain and symptom management consultations to team members and to patients primary
physicians

Preparing routine admission orders

Developing drug-use protocols
Making home visits as needed to assess medication
needs and use, and to educate patientdfamilies about
medication use
Common educational functions include:
Providing staff education in drug therapy for symptom
control and other indications
Providing education to patients and their families on
medication use
Providing physician education to hospice patient
primary physicians
Providing public education on drug use in terminal
care
Educating hospice volunteers about desired and
achievable outcomes from medication use
Providing clerkships for pharmacy students
Common dispensing functions include the following:
Dispensing prescription and over-the-counter medications, including therapeutic interchange
Providing for delivery of medications to patients
homes
Extemporaneous compounding of dosage forms that
are not commercially available
Providing home infusion service
Maintaining patient medication profiles

The broad range of relevant pharmaceutical services

needed by a progressive hospice program nearly always
requires more than one provider. Simple. informal needs
assessments of programs with which pharmacists want to
affiliate is an effective way to market their services.
Hospice Medicare payments and most other insurance
reimbursement is capitated (i.e., a flat daily fee is paid to
the program for all aspects of care). Therefore, the full
range of care must be provided within a defined cost
structure. Efficient formulary management, including
generic and therapeutic interchange and elimination of
unneeded drug therapy, can improve both patient care and
the fiscal health of the program. Patient and family
satisfaction are also important considerations for every
hospice program. Medication-related education provided
by a pharmacist can markedly increase satisfaction.
Hospice nurses often work relatively independently from

452

their patients physicians. Therefore, by providing nursing

education and consultation about patient assessment for
responses to therapy and about drug use, pharmacists can
increase their perceived need on the hospice team.

Most hospice referrals come to the programs from

patients primary physicians. Some come directly from
families who have heard about hospice from other
families that used the service or from presentations made
in the community. Most hospice programs send a nurse to
the paticnts home (hospital or nursing home) to assess
thc patient and to perform an intake evaluation. This
cvaluation requires a detailed history, including a
medication history.
Pharmacists need to know patients' prescription and
nonprescription medication intake; use of nutritional
supplements that may be pharmacologically active,
physical, and psychiatric diagnoses; and relevant laboratory test data when they are available. Usually, that
information is available from the primary physicians
referral and the documentation from the intake interview.
Frequently, laboratory test data arc not available because
of the hospice philosophy of only doing tests that will
directly affect paticnt outcomes. Renal function oftcn can
be estimated from the quantity and quality of thc patients
urinary output balanced against intake. Careful dose
titration is often needed in the absence of laboratory test
data as patients metabolic and elimination capabilities
decline. Sometimes, pharmacists make home visits to get
morc complete medication histories, and to ascertain the
familys understanding of medications and ability to
administer them correctly.

Most pharmacists will interact with terminally ill patients

or their family members at soinc time. Many pharmacists

Hospice and Palliative Care

will provide services to dying patients and hospice

programs. An increasing number of pharmacists will
work with hospice programs as a substantial part of
thcir practices.
Effective management of pain and othcr symptoms
associated with life-threatening disease is usually
attainable with the proper combination of pharmacological and nonpharmacological interventions. Pharmacists can, and should, play an important role in
ensuring that their patients receive this care when it
is needed.

EF
1. WHO Expert Committee. Cancer Pain and Palliative
Care; Technical Report Series, World Health Organization: Geneva, 1990; Vol. 804.
2. Lipman, A.G. Drug therapy for terminally ill patients. Am.
J. Hosp. Pharm. 1975, 32. 270-276.
3. Arter, S.G.; Lipman, A.G. Hospice care; a new opportunity
for pharmacists. J. Pharm. Pract. 1990, 3, 28-33.
4. Approaching Death: Improving Care at thi, End of Lije;
Field, M.J., Casell, C.K., Eds.; National Academy Press:
Washington, 1 997.
5. Berry, J.I.; Pulliam, C.C.; Caiola, S.M.; Eckel, F.M.
Pharmaceutical services in hospices. Am. J. Hosp. Pharm.
1981. 38, 1010 1014.
6. Arter, S.G.; Berry, J.1. The provision of pharmaceutical
care to hospice patient: Results of the national hospice
pharmacist survey. J. Pharm. Care Pain Symptom Control
1993, I (I), 25-42.
7. Lipman, A.G. Cumculum on pain for pharmacy students.
IASP Newsl. 1992 MayIJune, 2 ~ 4 .
8. Jacox, A.; Carr, D.B.; Payne, I<., et al. Management of
Cancer Pciin, Clinical Practice Guideline. AHCPR
Publication Number 94-0592, Rockville, MD. Agency
for Health Care Policy and Rescarch; U.S. Department of
~

Health and Human Services, Public Health Service,

1994.
9. Gavrin, J.R.An annotated guide to pain and palliative care
on the World Wide Web. J. Pain Palliat. Care Pharmacotherap. 2002, I 6 (2), 37 48.

PHAKMACY P KACTICE I SSU ES

ic

ai

Joaquin Ciraldez
Ana Ortega
Antonio ldoate
Azucena Aldaz
Carlos Lacasa
Clinica Universitaria de Navarra, Parnplona, Spain

INTRODUCTION
Hospital pharmacy service refers to the pharmacy that
is inside a hospital to serve inpatients and outpatients who
receive care in the hospital or require drugs that are only
delivered in hospitals. Hospital pharmacy practice
makes reference to all activities carried out by hospital
pharmacy service personnel to serve those patients.
In Spain, by law, there must be a hospital pharmacy
service in every hospital with 100 beds or more.] This
service must be under the supervision of a hospital
pharmacist. The total number of pharmacists depends on
different factors such as number of beds, services
provided to patients, and type of hospital. All hospital
pharmacists working in the service must be hospital
pharmacy specialists.
Activities common to all hospital pharmacy services in
Spain are pharmacy management, dispensing of drugs,
drug information, and drug manufacture. Many other
activities are also conducted in many hospital pharmacies
such as centralized parenteral admixture preparation,
design and preparation of parenteral and enteral nutrition
as well as follow-up of patients under this kind of
nutrition, therapeutic drug monitoring, pharmacoeconomics, drug surveillance, research, activities related to
medical devices, radiopharmaceutical activities, clinical
pharmacy activities, pharmaceutical care, participation in
committees, and so on.
In what follows, hospital pharmacy practice in Spain
will be described. As an introduction, a brief history and
description of the evolution of this discipline and the
Spanish hospital pharmacists training program will be
presented. Then, activities currently conducted by hospital pharmacy service personnel will be described and
clinical pharmacy opportunities will be indicated. And
finally, future trends will be outlined. Useful references
will be given throughout the report.
Encyclopedia of Clinical Pharmacy
DOI: 10.1081E-ECP 120006377
Copyright 0 2003 by Marcel Dekker, inc. All rights reserved

BRIEF HISTORY OF HOSPITAL

P H A ~ ~ A CINYSPAIN
Pharmacists have always worked with doctors and nurses,
in and outside hospitals, but it was not until 1955 that a
National Association of Pharmacists from Civil Hospitals
was created in Spain. In 1967, the Spanish Public Health
Service created its own hospital pharmacy services in
state hospitals. In 1977, hospital pharmacy services were
regulated as was the training of hospital pharmacists. In
1988 the name of the association changed to the Spanish
Society of Hospital Pharmacists, as it is known today.[311
In 1990, the Spanish Parliament approved the Medicine
Law ,I l l which consolidated hospital pharmacy services
as the basic structure for the rational use of drugs and
specified the residency program as the training needed to
work in those services.

Hospital pharmacy is a discipline in permanent transition.

In Fig. 1, activities conducted by hospital pharmacists as
well as the number of hospital pharmacists in Spain from
1955 are presented. Originally, hospital pharmacists were
responsible for management and delivery of stocks of
drugs to the wards. Since then the role of the pharmacist
has evolved to include a more rational dispensing system
(unit-dose delivery) and clinical activities and pharmaceutical care.
Hospital pharmacists in Spain, as in other countries,
are increasing their direct communication with patients,
nurses, and doctors and at the same time are transferring
some activities to others, such as drug manufacture to the
pharmaceutical industry. The therapeutic role of drugs is
increasing; furthermore, the responsibility of pharmacists
453

454

Hospital Pharmacy Practice in Spain

Quality management
1989- ADDlied research
Rational therapeutics
Coordination with primary care
Continued training
Etc.
1984.89

Clinical pharmacokinetics

00
1974-84
Committees
Team-work
Training
Drug information
Rational dispensin
1955 -74 Purchase
Manufacture
Control
Dispensing
Management

Number o f hospital

Fig. 1 Activities conducted by hospital pharmacists and the

number of hospital pharmacists in Spain since 1955.

goes beyond simple delivery of prescriptions. Clinical

pharmacy is appearing as a new culture for professional
practice. Clinical pharmacy can be defined as a compound
of beliefs, rules, and values that constitute the foundation
of the pharmacy practice, cooperation in the health care
team, and direct pharmacist interventions.[*] The objective is better patient care. Spanish health care organizations are incorporating this new role of the pharmacist in
different ways. An example is the addition of activities
involving direct contact with patients (clinical pharmacy
and pharmaceutical care) to the hospital pharmacist
training program.
Clinical pharmacy is founded on three basic activities:
drug selection, drug information, and rational distribution
(unit-dose). If these activities are not present, other
clinical activities cannot be developed. Drug information,
the unit-dose delivery system, parenteral and enteral nutrition programs, therapeutic drug monitoring, participation in clinical trials, and other activities developed by
Spanish hospital pharmacists are modest examples of
what is known as clinical pharmacy.[21Clinical pharmacy
is slowly changing society's idea of hospital pharmacy
in Spain.

is now four years. The reason for this extension is that

activities conducted by hospital pharmacists have increased considerably and training had to adapt to these
changes. Activities outside the pharmacy service and in
proximity to the patient and health care team are
necessary. In the fourth year, residents are supposed to
take their knowledge to the bedside and be with the
patient and health care team. They have to take responsibility for the pharmacotherapy given to each patient,
work as part of a team, and develop a critical ability to
solving all pharmacotherapeutic problems.[41 The residency program is regulated, practice-based, and can be
done only in certain accredited hospitals, and students
have to first pass a national exam.[32s361
Currently, approximately 100 pharmacists per year can be admitted to the
residency program, which includes all activities conducted in hospital pharmacy services.

CTlVlTlES CONDUCTE

Activities developed in a hospital pharmacy service can

be conducted either from inside the service or outside of
it. In the latter case, activities are obviously connected to
centralized activities.
In order to completely understand the situation in
Spain, it is important to know first how the Spanish health
system works. In Spain, there are public and private hospitals (around 795 hospitals; see Fig. 2).[301Every Spanish
person has the right to free public health care; however, if
patients prefer, they can go to a private hospital and pay
for the health care that they receive. In addition, some

V
In Spain, a hospital pharmacy training (residency) is
mandatory in order to work as a hospital pharmacist. This
specialization has been regulated by law since 1982.'3,291
Until 1999 the residency program lasted for three years; it

50

s b

Fig. 2 Number of hospitals per region in Spain (From

Ref. [30]).

Hospital Pharmacy Practice in Spain

private hospitals have agreements with the public sector

or with insurance companies.
In what follows, some activities conducted by Spanish
hospital pharmacists will be briefly described. Three activities are considered the foundation of hospital pharmacy in Spain: adequate drug selection, drug information, and drug delivery. Some Spanish references include
most of the activities developed at Spanish hospitals[73s1
as well as statistics on hospital activity."] Recommendations of the Spanish Society of Hospital Pharmacists
(SEFH) for some of the activities can be found at
www.sefh.es/normas/normasy.htm.
In addition, there are
now many possibilities for networking. The SEFH
facilitates interhospital communication and interest
groups have been created.13'I Some other international
organizations provide the same opportunities for their
specific topics (e.g., www.senpe.com/Gtrabaj/textos2.htm
for parenteral and enteral nutrition). Statistical data will
not be presented here but can be obtained from a survey
conducted by the SEFH in 1995;"01 more up-to-date
figures will become available from the year 2000 survey.

an

There are two important areas in management, clinical

and purchasing management. In every hospital pharmacy
service it is necessary to establish basic procedures for
drug selection, acquisition, reception, storage, and distribution with the least cost and risk for patients.
Clinical management refers to an efficient and safe use
of drugs according to pharmaceutical criteria. To achieve
this goal there are many possible courses of action; however, the most basic one, which is conducted in all Spanish hospital pharmacy services, is the definition of a
hospital-specific drug formulary that lists all the drugs
approved by the hospital's Pharmacy and Therapeutics
(P&T) committee. In Spain a hospital pharmacist is one
of the members of P&T committee, frequently the president or the secretary. The P&T committee has the following tasks: to select drugs; to recommend a drug use
policy; to educate about correct drug use; to set drug use
protocols and establish the means of ensuring compliance; to introduce a program for the detection, followup, and evaluation of adverse drug reactions; and to cooperate in a quality control program. Criteria used by the
P&T committee for drug selection are, in order of importance: efficacy, safety, cost-effectiveness, therapeutic
contribution, and incidence.
Regarding purchasing management, the main responsibility of the purchasing unit of a hospital pharmacy
service is to have available the necessary drugs to treat
hospital patients. Almost all purchasing units in Spanish

455

hospital pharmacies are computerized and all have the

following tasks: to define requested drugs. to establish
purchasing procedures according to Spanish law, to
place orders, to inform hospital directors of acquisitions,
and to develop a quality control program. Spanish references to management techniques are given in the

Drug dispensing/distribution is one of the main clinical

activities of Spanish hospital pharmacists. Many studies
have shown that the unit-dose distribution system has
reduced drug errors, and it is one of the main contributions of the hospital pharmacy['*] to patient care. Pharmacist participation in medical rounds and presence at the
time of prescription can result in even better patient care
and a prompter detection of treatment failures.[133141
Such
"clinical pharmacy" activity is being conducted with
some groups of patients in some Spanish h ~ s p i t a l s " ~and
'
is becoming more frequent.
Most Spanish hospitals have a unit-dose drug distribution system (Fig. 3). The main objectives of such a
system are the following: knowledge of patient pharmacotherapeutic profile, which encourages pharmacist intervention before drug dispensation and administration;
decrease of drug errors, interactions, and adverse reactions; reduction in treatment costs; decrease of drug manipulation by nurses on the wards; and billing or economic assignment according to each patient's real expenses.
In a unit-dose system, the pharmacy service delivers
drugs to be directly administered to the patient without
need of further intervention by others. In hospitals, the
distribution of some drugs (e.g., narcotics, compassionateuse drugs, research drugs, and drugs for emergencies)
requires a special control and distribution procedure.
Normally, these drugs are not sent with the rest of the
medication; and the procedure for these drugs will be
presented later on. The following is a description of the
unit-dose system as it is applied in most Spanish hospital
pharmacy services.
Medical orders are handwritten by doctors and a copy
is sent to the hospital pharmacy service, where it is recorded in the computer system. However, in some hospitals, doctors enter the medical order directly into the
computer; few proceed in this way at the moment but
the number is increasing. In a few hospitals, with some
types of patients, pharmacists are present at the time of
prescription. Prescriptions may specify generic or brand
names depending on the hospital's policy, and pharmacists can choose bioequivalent drugs depending on what
is available.

456

Hospital Pharmacy Practice in Spain

Fig. 3 Unit-dose area in a Spanish hospital pharmacy service.

Medical orders are checked by pharmacists. and doctors or nurses are consulted if necessary. At this point,
pharmacists have a good opportunity for intervention. To
prove the appropriateness of the prescription for a specific
patient, patient data must be checked. The unit-dose
system is computerized in all hospital pharmacies. Computer programs may be in-house or standard. Some
information can be checked on the computer; in some
cases programs even make suggestions.[16 Subsequently,
lists are created for auxiliary personnel to prepare the
delivery trolleys to take the medications to the wards. In
a few hospitals, for some specific units, automated delivery (e.g., PyxisE, Suremed, OmnicellT~)
is used. In
this case, pharmacists, or someone under their supervision, have to check the accuracy of the delivery content. Quality and security in delivering medication must
be fully guaranteed. These systems require a medical order, and information regarding patient name, doctor, and
quantity of drug dispensed must be recorded.
In most Spanish hospitals, there is just one delivery a
day, in the afternoon, because in many hospitals doctors
see patients between 8 A M and 3 P M However, the
number of visiting hours is increasing and pharmacy
working procedures may have to adapt to the new situation. Parenteral admixtures and nutritional preparations. if chemically stable, are generally prepared for each
patient in a centralized unit (described later), labeled, and

then delivered with the rest of the medication. Cytotoxic

drugs require special control and handling and are not
normally sent with the rest of the medication. Sometimes,
in intensive care units and other acute care settings, drug
delivery is not based on a unit-dose system but on stocks
kept on the wards.
Some outpatient services are provided by the inpatient
pharmacy, but discharged patients in Spain cannot receive
drugs from the inpatient pharmacy. At discharge, patients
may receive drug information and a copy of their medication administration record for reference. Computer
software (InfoWinE) has been developed by a Spanish
group (with a Spanish drug database) for this purpose.
Drugs that require a special delivery procedure are:

1. Drugs for compassionate use. Hospital pharmacists have to control the ordering, dispensing, and
use of compassionate-use drugs. These are drugs
for nonauthorized indications andlor research
drugs not included in a clinical trial. In Spain,
activities in relation to these drugs are regulated.[.71 In order to use a drug for compassionate
care, the pharmacy service of the hospital applies
to the Direccih General de Farmacia y Productos
Sanitarios with the following documents: a clinical
report in which the doctor justifies the application
for the drug, a consent form signed by the patient,

Hospital Pharmacy Practice in Spain

and a form signed by the hospital medical director

who is responsible for drug use. It is common
practice for the pharmacy service to prepare a
technical report with relevant references to support
the application and to inform hospital directors of
the process.

2. Research drugs. Regarding drugs for clinical trials

conducted at the hospital, the pharmacy service is
responsible for their reception, storage, dispensing,
distribution, and return of unused drugs. Spanish
requirements are that clinical trials be regulated.[17' A copy of the clinical trials committee approval must be kept at the pharmacy service, and
dispensing is done only after a written and signed
prescription is received.

3. Foreign drugs. Drugs marketed in a foreign country but not available in Spain may, according to
Spanish law, be obtained but only for the specific indications for which the drug is approved in
that foreign country."] The hospital pharmacy service applies to the Direcci6n General de Farmacia
y Productos Sanitarios with the necessary documentation for use with an individual patient or
according to a protocol.

457

macy service. A sterile area is normally achieved with a

vertical or horizontal airflow hood.

Centralized units of intravenous therapy (or CIVAS, for

'*central intravenous additive service' ') were created in
Spanish hospital pharmacy services as both a consequence
of the growing importance in the hospital of intravenous
drugs, and parenteral nutrition and fluids and as a
consequence of the clinical and technical progress in this
area of the pharmacy. In recent years. Spanish hospital pharmacy services are almost obligated to have a
CIVAS,"91 and it is now considered, along with the unitdose distribution system, one of the main units in the
pharmacy service.[l'] The main objectives of the CIVAS
are preparation of products therapeutically and pharmaceutically appropriate for the patient (right dose, administration route, chemically compatible, stable); preparation of admixtures free of particles, microorganisms,
or toxins; preparation of admixtures with the correct
drug in the exact amount; labeling, identification, storage, and distribution of admixtures according to good
drug control principles; cost control of intravenous
fluids; monitoring and clinical follow-up of patients;
drug use evaluation studies; and participation in the

4. Stocks in wards. There are some drugs (e.g.,

urgent medications, PRN, drugs dispensed as
needed) and medical devices that have to be in
stock on the ward. These are normally sent to the
floor on a regular basis, according to a fixed
schedule. These stocks are periodically checked
by pharmacists (with regard to composition, expiry date, correct identification), and the results of
the control are filed. The nurse supervisor of each
ward is responsible for the safekeeping of the
stock; the pharmacist is responsible for control
and supervision.

Manufacture
Manufacture implies the manipulation of active substances and drugs in order to make them suitable for direct
administration to patients. Separate areas are needed for
the manufacture of intravenous admixtures and parenteral
nutrition, cytotoxic drugs. and sterile preparations. No
separate areas or biological security are needed for other,
nonsterile preparations or drug repackaging. Following
Spanish regulation,"*] written protocols and procedures
for manufacturing processes must exist in every phar-

Fig. 4 Nurse preparing an anticancer drug in a central unit in

a Spanish hospital pharmacy service.

458

intravenous therapy policy of the hospital (indications,

selection, preparation, administration, etc.).
Most hospitals have a computerized CIVAS that is
integrated into the unit-dose distribution system. Preparations handled in these units include cytotoxic drugs,
antibiotics. parenteral nutrition, other drugs, and therapy with fluids (Fig. 4). References to Spanish articles
dealing with recommendations for managing these units
can be found in the b i b l i ~ g r a p h y . ~Pr~otocols
~ ~ , ~ ~must
.~~~
include every procedure carried out in the unit, from
preparation to identification, hazard handling, waste treatment, and so on. In Spain, admixtures and nutritional
preparations are normally prepared by pharmacy nurses
supervised by pharmacists.
Centralized units have some advantages, such as less
investment in equipment, better use of multidose vials,
recycling of unused preparations, better working conditions, a good opportunity for clinical intervention by
pharmacists, and improvement in the quality of patient
care when the CIVAS is well coordinated with the unitdose system.

Hospital Pharmacy Practice in Spain

established in Spain, and today activities related to drug

information are part of every hospital pharmacy service.
Drug information is another area where clinical intervention by pharmacists could be increased.
Information provided by pharmacists can be classified
as passive or active. The former includes answering
questions and preparing the requests/controls for foreign,
compassionate-use, and research drugs. Active information includes providing support to the P&T committee
(drug formulary preparation, diffusion of main decisions),
establishment of protocols, writing of the drug information bulletin, sessions, adverse drug reactions programs,
advising in- and outpatients, health education activities,
information management, and so on. Some hospitals make
their drug formulary and other information available on
the Internet (e.g., www.hsanmillan.es/farma/index.htm)
and some participate in the dissemination of drug information, in the Spanish language, to patients.[321 Additional sources of information and recommendations for
the management of drug information centers that have
been proposed by the SEFH and others are given in the
bibliography. [7,8,11,21,221

Enteral and Parenteral

In Spain. preparation of enteral and parenteral nutrition is
carried out in the centralized units of the pharmacy services. Hardly any hospitals obtain their parenteral
nutrition preparations from an external company. In most
hospitals there are some standard nutritional preparations
as well as others designed for specific patients. Nutrition
design and patient follow-up is done by hospital pharmacists or by a team of various professionals (doctors,
dieticians, nutritionists, pharmacists), depending on the
hospital. Normally. laboratory data, clinical results, and
patient progression are observed by pharmacists and
nutrition support is changed accordingly, which gives
pharmacists another opportunity for clinical intervention.
References on how to manage such a service are given
in the bibliography.[73x3191
Computer software is used to
make this task easier, permitting data entry (general
patient data, lab results, prognosis, nutritional status, diet)
and preparation of working sheets, reports, and labels for
nutrition identification. Complications or incidents can
also be registered; some software programs include
Spanish products for nutrition support (e.g., NutriDataE,
Nutri2000E).

Drug information
Drug information is one of the main responsibilities of
pharmacists in hospitals and one of their most important
contributions to a rational use of drugs and better patient
care. In 1973, the first drug information center was

harmacok~~etic
and
Therapeutic Drug ~ ~ ~ i t o r ~ n g
Clinical pharmacokinetics is a multidisciplinary field that
has been growing in importance over the last 20 years. Its
main objective is therapy optimization by achieving drug
concentrations in the therapeutic range and thereby
obtaining maximum efficacy with minimum adverse effect. The concentration-effect relationship of many drugs
is better than the dose-effect relationship. This is due to
high interindividual variability. In these drugs, therapeutic
drug monitoring is justified.
To assure the best efficacy, the pharmacist designs a
pharmacotherapy that is specific to each individual patient. This is achieved by obtaining blood samples, gathering patient data (clinical situation. laboratory results,
physiopathology, progression, therapy), applying pharmacokinetic principles, and applying knowledge of drug behavior in the population in which the patient is included.
Even though drug concentration is an important piece of
information, it is not enough on its own and patient
follow-up is required. Times of sample collections must
be carefully established in order to obtain maximum information from the minimum number of samples.
The usefulness of therapeutic drug monitoring has
been demonstrated for some drugs (e.g., some antibiotics,
cardiovascular agents and antiepileptics, theophylline, inmunosupressants, litium, r n e t h o t r e ~ a t e ) , [ ~and
, ~ ~these
I
are
the drugs that are included in clinical pharmacokinetic
programs in Spanish hospital pharmacy units. The be-

Hospital Pharmacy Practice in Spain

nefits of therapeutic drug monitoring of other drugs, such

as some anticancer drugs, are now being studied in some
centers.[241
Sample analysis requires specific techniques, such as
fluorescence polarization immunoassay (FPIA) and highperformance liquid chromatography (HPLC). These techniques are not always available in the pharmacy and so
sample analysis is not always done in Spanish hospital
pharmacy services but in laboratories. However, it is a
pharmacist who interprets results, makes recommendations, and follows up on patients, all as part of clinical
activities to pursue better patient care. In all hospitals with
such a pharmaceutical service, doctors and other members
of the health team welcome the contribution of pharmacists, with their pharmacokinetic knowledge, to the
rational use of drugs.

Drug Surveillance
Drug surveillance includes drug follow-up with the purpose of observing, evaluating, and communicating any
adverse reactions that a drug can produce when used in
clinical practice. A drug surveillance program must be
established in every hospital in order to detect these
reactions, and the drug information center must support
this activity technically. Observed events are communicated to the regional center for drug surveillance, either
directly or through the SEFH. The Spanish Drug Agency[331facilitates drug surveillance activities and the diffusion of information among professionals. Spain has
an organized drug surveillance system-a national committee reporting to the Ministry of Health was constituted for this purpose in 1987. Spontaneous communication of adverse drug reactions is voluntary in Spain
and is conducted through an official form known as the
"yellow card.'"']

Radiopharmacy
In Spain, pharmacy practice is also applied to the study,
manufacture, control, and distribution of radiopharmaceuticals. Radiopharmaceuticals must be isolated from
other drugs and personnel, and devices must follow Spanish regulations.[251Radiopharmacy is part of the hospital pharmacy service; however, it is recommended that
the unit be located close to the nuclear medicine department and supervised by a pharmacist specialist in
radiopharmacyI'[.

459

Spain, pharmacoeoconomics is becoming more important

due to increased pressure to make the best use of limited
resources. Furthermore, advances in the methodology[261
have increased the scientific rigor of pharmacoeoconomics. Pharmacoeconomics is used by Spanish hospital
pharmacists as a tool for decision making regarding
drugs, medical devices, or related activities. Studies are
conducted and pharmacists adapt published studies to
each unique hospital setting.

Many Spanish hospital pharmacies participate in the

selection, ordering, storage, distribution, and provision of
information relating to medical devices. Such hospital
pharmacies are also involved in rational use programs. A
guide to medical devices used in Spanish hospitals has
been published, which gives a classification to each
device.[271

The number of activities conducted by hospital pharmacy

services is continually increasing as the needs of doctors,
personnel, and patients evolve. This gives the pharmacist
the opportunity to develop a range of activities (clinical
roles, management, administrative duties) that are of
interest to and positive for the hospital. Pharmacists must
continue to focus on the impact that technological and
professional changes may exert on the efficacy and safety
of medications as well as on patient care.
The role to be played by hospital pharmacists should
be determined by all health care professionals, not just by
pharmacists themselves. The 1999 meeting of the Spanish
Society of Hospital Pharmacists took this into account
and a roundtable was held incorporating representatives
of all health team members as well as a representative of
patient opinion based on a survey of patients. Better
information for patients, more integration of pharmacists
in the health team, and more direct contact with patients
seem to be the activities to be developed in the future.[2s1
Any activity that contributes to patient care must be
nurtured, no matter who suggests it. Pharmacists as well
as other professionals know that teamwork is the key to
improving results for the patient.

Pharmacoeconomics
Pharmacoeconomic evaluations consist of comparing
different alternatives in terms of costs and benefits. In

1. Ley 25/1990, de 20 de Diciembre, Boletin Oficial del

Estado (B.O.E.) del 21. del Medicamento. (Also at
www .msc.es/farmacia/legislacion/home.htm).

Hospital Pharmacy Practice in Spain

460

2.

Bonal, J . Management en Farmacia Hospitalaria. I n

I.'armnc,iu Hospitalaria, 2nd Ed.; Editorial MCdica Inter-

3.

4.

5.

6.

7.

8.

9.

10.
1I.

12.

13.

14.

15.

16.

national: Madrid, Spain, 1992; 30-55.

Suiik, J.M.; Rel. E. Coinpilucirjnde Legislario'n en I*hrmacin Ho,spilalaria, 2nd Ed.; Sociedad Espaliola de Farmacia Hospitalaria, Ed.; International Marketing and
Communications: Madrid, Spain, 1994; 1290.
Gitici de Formacidiz de l.q~c~ia1i.sta.s.
Famiacia Hospitalaria; Ministcrio de Sanidad y Consumo, Ministerio de
Educacihn, Cultura, Conscjo Nacional de Especialisaciones Farmac6uticas: Madrid, Spain, 1999; 3 1.
SuliC, J.M.; Bel, E. Legislacidn. In Fnrmariu Hospitdaria,
2nd Ed.; Editorial Mkdica Internacional: Madrid. Spain.
1992; 172-268.
Simh, R.M. Docencia. In Farmacia Hospi~ularia,2nd Ed.;
Editorial MCdica Intcrnacional: Madrid, Spain, 1992; 136157.
Guia de Gestio'n d r 10s Suvicios de F a m a t i n Hmpitalaria; Insituto Nacional de la Salud: Madrid, Spain, 1997,
(A1so at w w w .se f.es/guiafarmacia/home. h tm) .
Farinacia Hospitdaria, 2nd Ed.; J. Bonal, A. Dominguez(31. Dir.; Editorial MCdica Intcrnacional: Madrid, Spain,
1992, 1717 pp.
Guia para la Evaluucicin y Mejora de 10s Servicios de
Farmacia Hospitalaria; Insituto Nacional de la Salud:
Madrid, Spain. 1998, (Also at www.sef.es/guia/index.htm).
Situacihn de la Farinacia Hospitalaria. Encuesta- 1995.
SEFH Bol. Inf. 1996, XX (76), 100.
Curso de Adnziiiistrcicidn de Servicios I-lospitalarios de la
Clinicti Univei~itaria.El Sewicio de Farmacia: Universidad de Navarra: Pamplona, Spain. 1992; 509.
Ferrandir, J.K. Distribucihn unidosis dc Mcdicarncntos en
Hospitales. In X I X Asciniblpa National de Farmare'ulicos
de Ho.spita1e.s; Graficas Orihn: Madrid. Spain, 1975; 7 1 88.
Lcape, L.L.; Cullen, D.J.: Clapp, M.D.; Burdick, E.;
I>cmonaco, H.J.; Erickson, J.I.; Bates. D.W. Pharmacist
participation on physician rounds and adverse drug events
in the intensive care unit. JAMA, 1. Am. Med. Assoc.
1999. 282 (3). 267 270.
Scroccaro, G.; Alhs Almiiiana, M.: Floor-Schreudcring,
A,; Hekster, Y.A.; Huon, Y. The need for clinical
pharmacy. Pharm. World Sci. 2000, 22 ( l ) , 27 -29.
Atencihn FarmacCutica. In XIIV Congreso de la SEFH,
Pamplonci, Sept. 1999; Farm. Hosp.. 1999; Vol. 23, 3-6,
(Num. Especial).
Codina Jane, C. In Si.steiiza.s Expc,rto.r y Aplicacioiws 111XLTV Congreso Nacional de Farmacia Hospitalaria, Pamplona, Spain, Sept. 1999: Sociedad
Espafiola de Farmacia Hospitalaria: Madrid, Spain, 2000.

17. Real Decreto 561/1993, del 16 de ahril. Boletin Oficial del

Estado de 13 de Mayo. por el que sc estahlecen 10s
requisitos para la realiLacihn de cnsayos clinicos con
mcdicamentos.
18. Normas de correcta faabricacihn de fdrmulas magistrales y
preparados oficinales. SEFH Bol. Tnf. 1994, XVIII (69),
15 28.
19. JimCneL Torres, N.V. Mezclas, 1ntmveno.sa.s y Nutricicin
Artzfi'cial, 4th Ed.: C.E.E. Convaser: Godella, Valencia,
Spain, 1999; 722.
20. Manejo de Mrdicainentos Citostciticos, 2nd Ed.: Asociacidn Espaliola de Farmackuticos de Hospitales: Madrid,
Spain. 1987; 56.
21. Proyecto de recomendaciones de la SEFH: Informacidn de
medicarnentos. S E H Bol. Tnf. 1996, X X (77), 15 20.
22. Tordera, M.; Magraner, J.; FernBndez, M.I. Informacionde
medicarnentos e internet. Estrategias de btisqucda farrnacoterap6utica en la World Wide Web. Farm. Hosp. 1999,
23 (l), 1-13.
23. Applied Pharmacolzinetics. Principles of Therapeutic Drug
Monitoring, 3rd Ed.; Evans, W.E., Schentag, J.J., Jusko,
W.J.: Eds.; Applied Therapeutics, h e . : Vancouver, Washington, 1992.
24. AldaL, A. FarmacocinCtica de CitostBticos. Conceptos
Generales. In El Paciente Oncohematolrigico y su
Tratainirnto. Mddulos d~ Acrualizncicin Multidi.sciplinar;
SEFH, Editores Medicos, S.A.: Madrid, Spain, 1997; 3237.
25. Real Decreto 479/1903, de 2 de Abril, por el que se regulan 10s medicamentos RadiofBrmacos de uso hurnano
( I ) . Boletin Oficial del Estado nuin 109 de 7 de Mayo
de 1993.
26. Drummond, M.I:.; O'Brien, B.; Stoddart. G.L.; Torrance,
G.W. Methods ,for IZconomic Evaluation of Health Care
Pi-ogmmmes, 2nd Ed.; Oxford University Press, Tnc.: New
York, 1997; 305.
27. Giraldez, J.; Idoate, A,; Romero, R.; Urstia, C.; Errea,
M.T.; Lacasa, C.; AldaL. A. Guiu de P m d u c t o . ~Sanitarios,
2nd Ed.: ELNSA: Raraliain, Navarra, Spain, 1998; 508.
28. In El Medictrmenro en e l Prnceso de Atencio'n a1 Pacieizte.
Anu1i.si.s MLilridisci(r1inar. Poncncias XLIV Congrcso
Nacional dc Farmacia Hospitalaria. Pamplona: Spain,
Sept. 1999; Sociedad Espafiola de Farmacia Hospitalaria:
Madrid, Spain, 2000; 9-64.
29. Text available at www.msc.es/farmacia/legislacion/
home.htm
30. www.msc.es/centros/catalogo/home.htm.
31. See www.scih.es.
32. See www.viatusalud.coin.
33. See www.msc.es/agemed/.

PROFESSIONAL DEVELOPMENT

Oregon Health Sciences University, Portland, Oregon, U.S.A

INTW
Hyperlipidemia is a disorder that is widely prevalent in
the U.S. population. Elevations of total and low-density
lipoprotein (LDL) cholesterol have been documented to
increase the risk of coronary heart disease (CHD). The
Third National Health and Nutrition Evaluation Survey
(NHANES 111) estimated that 52 million Americans have
cholesterol elevations that require intervention, of which
12.7 million may require drug therapy."] A number of
studies have shown a reduction in cardiovascular mortality or morbidity with lipid-lowering therapy in
subjects with CHD (secondary p r e v e n t i ~ n ) [ ~ -and
~ I in
some patients without known CHD (primary prevent i ~ n ) . ' ~Despite
'~]
this, the use of lipid-lowering agents in
patients who have had a prior coronary event is disturbingly low.[81When drug therapy is initiated, compliance may be poor and adherence to therapy may be as
low as 35% in some s e r i e ~ . ~ ~Other
" ~ ' data indicate that
even where cholesterol-lowering drugs are prescribed,
many patients do not reach the goals of therapy recommended by the National Cholesterol Education
Program (NCEP).'"'
Hyperlipidemia is a disease particularly suitable for
pharmacist management for a number of reasons. It is a
disorder that can be diagnosed and monitored primarily
by laboratory testing. There are accepted guidelines for
LDL goals. The drugs that are used vary in their effectiveness for altering the different lipoproteins and
require someone skilled in this knowledge to select them
for use. The rate of adherence to drug therapy is low,
possibly in part because patients do not feel elevated
cholesterol and therefore do not understand the need to
take medication. These drugs are in some cases unpalatable or difficult to tolerate and require much patient
education to initiate therapy and maintain compliance.
Drug interactions with cholesterol-lowering agents can be
clinically significant. These include inhibition of absorption of drugs such as levothyroxin or warfarin given concurrently with bile acid binding resins, or inhibition of
the metabolism of statin drugs resulting in myopathy or
even rhabdomyolysis.
Eneyelopedin of Clinical Pharmacy
DOI: 10.1081/E-ECP 120006308
Copyright 0 2003 by Marcel Dekker, Inc. All rights reserved.

Pharmacist intervention was effective in maintaining

compliance and achieving LDL goals in patients treated
with colestipol."*] In a small study at a Veterans Administration (VA) Medical Center, patients received 1 hr of
education and assessment by pharmacists before initiating
colestipol therapy. They also were telephoned at 2-week
inervals until an 8-week follow-up appointment. They
were contacted by telephone again at 26 and 52 weeks.
When compared at 52 weeks with patients receiving usual
care, the pharmaceutical care group had greater persistence with colestipol therapy, were taking higher doses,
had lower mean LDLs, and had a higher rate of reaching goal.
The effect of weekly contacts with patients initiated on
combination lipid-lowering therapy of lovastatin and colestipol was inve~tigated."~]
Patients from a universityaffiliated tertiary care center were enrolled if they had
undergone coronary artery bypass graft surgery or percutaneous transluminal coronary angioplasty (PTCA). In
addition to instructions on appropriate drug use prior to
hospital discharge, patients were telephoned at home
weekly for 12 weeks at which time "emphasis was placed
on the importance of therapy in reducing the risk of
cardiac events." Interestingly, when these patients were
compared with a control group at the end of the 12 weeks
compliance with therapy was high in both groups and not
significantly different. However, when refill history was
obtained from the patients' pharmacies at 1- and 2-year
intervals, the patients in the intervention group had significantly higher rates of compliance.
Provision of patient education in combination with bimonthly cholesterol testing in a community pharmacy resulted in a significant reduction in cholesterol values over
a 6-mo study."41 Changes in patient-reported behaviors
such as dietary habits and exercise were also noted. Although the lack of control group made this study less than
definitive, it indicated that a combination of cholesterol
monitoring and education could result in lower cholesterol
concentrations. A second study demonstrated that screen461

Nyperlipidemia Pharmacy Practice

462

ing in combination with education and referral to a primary care physician when appropriate resulted in a significant
number of patients receiving follow-up for cholesterol
concentrations that were higher than the NCEP goal^."^'

Hyperlipidemia management can exist wherever pharmacists practice, including community pharmacies, institution-based or free-standing ambulatory clinics, or
inpatient services. Despite these different settings, some
universal requirements need to be addressed.
The nature of the practice may be influenced by the
availability of space in which to provide patient care. For
example, the lack of facilities in which to meet privately
with the patient may result in a telephone-based practice.
Offering lipid management in the community pharmacy
may require an investment in infrastructure. Some remodeling of the pharmacy may be needed to provide an
area where confidential communications can occur. A
lipid analyzer, as well as a dedicated clean area, must be
supplied if blood lipid monitoring is to be offered.
Staffing must be adequate. A redistribution of duties
among pharmacists and technicians, possibly in addition
to hiring additional pharmacists, may be necessary to
allow pharmacists time to provide the service."61
Most pharmacists will need to justify their provision of
this service, whether it be in the form of a business plan
for an independent pharmacist or a proposal demonstrating benefit to an institutional employer. If the pharmacist
will be relying on referrals to the service or will be
collaborating with physicians to implement therapy, the
pharmacist must first determine whether physicians will
use the service and be accepting of input. An evaluation
of a cholesterol screening program found that a significant
number of physicians in the geographic area were resistant to their patients directly receiving the results of
their cholesterol tests from the pharmacy. These physicians were less likely to contact patients with the results
of elevated cholesterol values obtained at the screening."71 Patients may also be surveyed as to acceptance of
pharmacist management, particularly if they are going to
be expected to pay part or all the costs of the service.
In all models, a scope of practice agreement or protocol is recommended, if not required. This should outline
the following:

1. The hours of operation.

2. The pharmacists who are responsible for providing
the service.

The supervising physician, if applicable. This may

be especially needed if the pharmacist has prescriptive authority.
The population to be managed. For example, in the
case of limited resources, the service may be restricted to secondary prevention patients, patients
requiring combinations of drugs, or those with
mixed lipid disorders versus those with only elevated LDL, or other parameters as determined by
the needs of the facility.
The means of identification of patients. This could
vary from seeing potentially low-risk patients,
such as any patient followed in a general medicine
clinic or referred by a primary care provider, to
identifying high-risk patients, such as anyone discharged from the hospital with a diagnosis of
myocardial infarction or after a revascularization
procedure or with other evidence of CHD risk.
The goals of the clinic and methods for achieving
them. Explain how patients will be evaluated and
how the need and type of therapy will be determined. Describe any protocols for deciding on
drug therapy or the rationale for allowing clinical
decision making instead of following an algorithm.
Will patients be seen once for evaluation and recommendations, as often as necessary to achieve
control, or indefinitely? How frequently will they
be seen? Will all contacts be by visit, or will telephone calls be routinely used?

The functions of a pharmacist in lipid management in a

community setting may include screening for elevated
cholesterol and/or low HDL cholesterol, providing patient
education and counseling to enhance adherence with drug
and nondmg therapy, monitoring of lipid profiles for assessment of efficacy, and making recommendations to
providers for drug therapy management.

Screening programs
The accessibility of community pharmacists to both patients and physicians makes them an ideal resource for
identifying the presence of lipid abnormalities. Screening
may consist of offering to measure cholesterol levels to
the general population, or may involve targeted screening
of patients at high-risk for CHD, also called case finding.
In either case, screening should involve more than pro-

Hyperlipidemia Pharmacy Practice

vision of a laboratory value. The total and HDL cholesterol values should be evaluated and interpreted in the
light of the patient's risk factors for CHD. Education
about cholesterol and cholesterol-lowering strategies
should be provided, and the pharmacist should be prepared to refer the patient to their primary care provider if
warranted. Failure to interpret these values may result in
unnecessary concern on the part of the patient or, potentially more damaging, result in a patient not seeking
care when needed.
Gardner and colleagues['s1 demonstrated that a community pharmacy prescription database can be used to
identify patients at risk for CHD. This is important
because it targets those individuals most likely to benefit
from lipid-lowering interventions. They identified four
clinical indicators that were believed to be likely to
identify patients at risk for CHD: prescription for sublingual nitroglycerin, prescription for beta-adrenergic
blocking agents or thiazide diuretics, males with a prescription for nicotine gum or patch, or those receiving oral
hypoglycemic agents or insulin therapy and who were
greater than 50 yr of age. A search of the pharmacy
database was performed to identify individuals prescribed
at least one of these agents, and the pharmacy profiles
were screened to ensure the age and sex met the criteria.
These subjects, who were invited to a free cholesterol
screening, were compared with an unselected population
who self-referred to the screening. Twenty-one percent of
those identified as high risk responded to the invitation. A
significantly greater percentage of the screened patients
had cholesterol values that were higher than desired. In
addition, two-thirds to three-fourths of the patients with a
clinical indicator had cholesterol values over 200 mg/dl,
indicating that these indicators may be predictive of the
need for cholesterol-lowering intervention.
Einarson et a ~ [ 'reported
~]
the financial feasibility of a
pharmacy-based cholesterol screening program. Subjects
were asked how much they would be willing to pay for a
cholesterol measuring service in a pharmacy. Patients
who completed a pharmacy service questionnaire indicated they would be willing to pay a mean of S11.54.
Patients who received the service were surveyed afterward, and indicated a willingness to pay $14.47 (1987
dollars). Of note, it does not appear that these patients
received pharmacist education as part of their testing but
were reacting to the value of obtaining cholesterol results
at a pharmacy.

Lipid management practices

Shibley and Pughi201 described the provision of pharmaceutical care in independent community pharmacies.

463

Patients were recruited by the investigator and included in

the study if their primary physicians agreed to allow them
to do so. The physicians were recruited by letter and by
meetings with the pharmacists. Pharmacists provided
basic education about lipid disorders, the relationship to
coronary artery disease, and diet and exercise. Lipoproteins were measured at the pharmacy using the CholestechE analyzer. If warranted, drug therapy recommendations were provided to the physician via telephone or
letter; if accepted, the patient was seen at 2 months to
assess efficacy and adverse effects. All patients were also
seen by a certified dietician. Significant reductions in
LDL cholesterol were observed, although it is not clear
how many patients reached their therapeutic goal. Given
choices ranging from $15 to $55, patients indicated they
would be willing to pay $23.75 &$11.42 for each encounter with the pharmacist.
Project ImPACT: Hyperlipidemia was a multicenter
community pharmacy-based demonstration project that
aimed to demonstrate the benefits of a pharmacist on
patient adherence and compliance with lipid-lowering
therapy.[16] The pharmacists used cholesterol analyzers at
their sites to enhance their interactions with patients and
their physicians. Emphasis was placed on patient education and communication with the physicians to bring
patients to their NCEP cholesterol goals. Of interest,
62.5% of the patients, who were predominantly primary
prevention, did reach and maintain their goals by the end
of the study. Persistence with therapy was excellent, with
93.6% remaining on the prescribed cholesterol-lowering
agent throughout the study. Compliance with therapy,
defined as fewer than five missed doses or refills obtained
within 5 days of when due, was 90.1%. Physician acceptance of pharmacist interventions was high, with 76.65%
of recommendations resulting in a change. These interventions involved coordination of care, adverse drug reactions, drug interactions. drug dosing, drug selection, and
side effects.
The participating pharmacies were primarily independents, with some chains, clinic pharmacies, health maintenance organizations, and home health/home infusion
pharmacies. All pharmacies scheduled patients for appointments with the pharmacist. Most used time before
the regular pharmacy hours or on weekends, as well as
during usual business hours. Seventy-two percent of sites
changed the pharmacist's duties to accommodate this new
role, and 59% changed technician duties. Increasing pharmacist overlap was also a commonly used strategy. Fewer
than one-third added pharmacist staff to implement the
program. The average amount of time spent on patient
encounters was about 45 min for a new patient and 22 min
for a follow-up appointment.

464

Development of lipid management practices in the institutional or free-standing clinic settings may take many
forms. The types of practice can range from provision of
consultative services by pharmacists in conjunction with
patients appointments with their primary care provider,
to free-standing pharmacist-managed clinics in which the
pharmacist has prescriptive authority to initiate, discontinue. and change drug therapy.
Pharmacists in a consultative role improved management of lipid disorders in an ambulatory internal medicine
In this study, the pharmacist met with patients
prior to their physician appointment. Medication histories were taken. compliance encouraged, drug costs were
tracked, and the least costly recommendation made to the
physician. The pharmacist reviewed laboratory data and
recommendations with the physician and attached a copy
of these to the front of the chart. Decisions to accept or
decline the recommendations were made by the physician.
The majority of recommendations were accepted. When
compared with usual care where pharmacists were not
involved, significantly more patients reached LDL goals.
Furmaga[**] described the structure of a pharmacistmanaged lipid clinic at a VA Medical Center outpatient
clinic. Initially patients were identified using the hospital
computer database to identify those with a total cholesterol of greater than 260 mg/dl. These patients were
invited to a general educational seminar and subsequently
scheduled into the lipid clinic, if needed. As this resulted
in more patients identified than could be reasonably
accepted into the clinic, the system was changed so that
patients were referred from outpatient clinics. Patients
were scheduled for 30-min appointments. The activities of
the pharmacist included patient education, identification
of secondary causes of hyperlipidemia with subsequent
referral to other clinics as indicated, compliance assessment, and intervention and recommendation of addition of
drug therapy to diet therapy. Clinical judgment was used
in lieu of a protocol for drug selection. The pharmacist did
not have prescriptive authority but was responsible for
monitoring of drug therapy for efficacy and adverse
events, and determining when changes were needed. Activities were documented in the medical record.
Shectman and colleagues[231demonstrated that use of
physician extenders resulted in improved LDL cholesterol
concentrations when compared with usual care. In this
model, also at a VA hospital clinic, the pharmacist or
nurse used an algorithmic stepwise approach to assist in
drug selection and optimization in reaching NCEP LDL
goals. More patients reached their LDL goals in the
physician extender group. The total costs of the physician

Hyperlipidemia Pharmacy Practice

extender care was higher. primarily due to higher drug

costs. The cost per unit of LDL lowering, however, was
significantly less.

Inpatient pharmacists can also provide care by helping to

initiate lipid-lowering therapy. In addition to the data that
support treatment to lower cholesterol in patients who
have had a coronary event, the National Committee for
Quality Assurance is instituting a new Health Plan Employer Data and Information Set (HEDIS) indicator for
cholesterol management in patients who have experienced
an acute cardiovascular event. This will provide a challenge to identify and treat patients with coronary artery
disease. A program by which pharmacists identified patients through acute myocardial infarction/percutaneous
transluminal coronary angioplasty orders has been detailed.[241Pharmacists placed a standardized note on the
outside of the patient chart that included the goals of
therapy and recommended that a lipid panel be obtained.
The proportion of patients receiving lipid-lowering therapy at discharge was significantly increased after initiation of the program.

harmacist Education and Trainin

Regardless of the practice setting, a pharmacist needs
certain tools to provide lipid management services. The
first tool is an in-depth understanding about the disease
and antihyperlipidemic drugs. Understanding of the disease includes knowledge about lipid metabolism, the influence of lipids on atherogenesis and vascular function,
the risk of dyslipidemia and CHD mortality and morbidity, and the benefits of lipid-lowering as demonstrated in
clinical outcome trials. Knowledge of the drugs includes
pharmacology, pharmacokinetics (especially as pertains
to the potential for drug interactions), adverse effects that
are most often experienced or most severe, and how to
manage these effects. The influence of each drug on the
various lipoproteins, the effects of dose on lipoprotein
lowering, the risks and benefits of combination therapy,
and the goals to be targeted should be known. This type of
education can be obtained through self study or by attending certificate programs, conferences, or other training programs.
The American Pharmaceutical Associations Pharmaceutical Care for Patients with Dyslipidemias is a

465

Hyperlipidemia Pharmacy Practice

2-day training session that includes material on evidence

of cholesterol-lowering and use of antihyperlipidemic
agents, training on the CholestechE analyzer, discussions
on preparing the pharmacy practice site to provide the
service, marketing to patients and physicians, communication with physicians, and reimbursement and billing.
The National Pharmacy Cardiovascular Council offers a
comprehensive three-tiered educational program. The Lipid Managers Training Program begins with the basics
of lipid disorders and progresses to on-site training in a
lipid clinic.[321Many state organizations offer certificate
programs in lipid management.
The NCEP was initiated by The National Heart, Lung,
and Blood Institute (NHLBI) of the National Institutes of
Health (NIH) in 1985. The goal of this program is to
promote cholesterol awareness in the U.S. population as a
risk factor for CHD and provide guidelines for cholesterol-lowering to physicians, patients, and the community, thus reducing CHD mortality and morbidity. The
program consisted of five panels that are responsible for
evaluation of the evidence and establishing guidelines in
PATIENT NAME
REFERRING CLINIC/ PROVIDER

ID#

their specific areas: the Expert Panel on Detection,

Evaluation, and Treatment of High Blood Cholesterol in
Adults (Adult Treatment Panel or ATP) develops guidelines for the detection, evaluation, and treatment of high
blood cholesterol in adults; and the Expert Panel on
Blood Cholesterol Levels in Children and Adolescents
developed recommendations for healthy diets for children
and adolescents, and for detection and treatment of high
blood cholesterol in children and adolescents from highrisk families.
The guidelines for treatment recommended by the
ATP are considered the standard for dietary and drug
therapy in adults. The most recent guidelines were released in May 2001;r251the panel is currently revising
these and updated guidelines are anticipated after Spring
2001. The pediatric guidelines were released in 1992.r261
The American Diabetes Association clinical practice
guidelines make recommendations for managing hyperlipidemia in persons with diabetes that are more aggressive than the current NCEP guidelines, as well as more
specific to this population.[271
DOB
HT:
PRIOR DIETARY CONSULT / INTERVENTION?

DX:
SMOKER?
RISK FACTORS:
MALE > 45 YR
DIABETES
HTN

ETOH? (QUANTITY):

FEMALE > 55 YR
SMOKING
CVD

LDL GOAL

TG GOAL

CHD
FAMILY HX
PVD

Fig. 1 Sample lipid monitoring form.

HDL > 60?

Hyperlipidemia Pharmacy Practice

466

atie

ucation

not be product specific but will contain a company logo

and product brand names.

The second set of tools involves imparting some of this

information to the patient. This can be done verbally,
with written educational materials, with videotapes, or a
combination thereof. The level of the material should be
adjusted for the educational level of the patient population. The information should include definitions of
cholesterol, triglycerides, and lipoproteins; factors that
increase or decrease these values; and the goals for the
patient. A risk calculator that can be used to illustrate to
patients how their individual factors increase or decrease
their risk of a coronary event should also be included.[2s1
In patients without physical limitations, handouts and
counseling about beginning an exercise program may be
provided, although patients with known vascular disease
should be referred to their primary care provider for
guidance on appropriate activity. Providing a diary in
which patients can document their activity, heart rate,
notes on dietary changes, and weights can be helpful,
especially in the initial stages of making lifestyle
changes. Information sheets about the individual drugs
should also be distributed. The American Heart Association (AHA) web site provides a variety of tools for the
health care provider to order for a fee or to download at
no charge.[291
Pharmacists who practice lipid management should be
familiar with dietary factors that influence lipids. If
referrals to a dietician are allowed by law, the pharmacist
should have a referral base from which to guide the patient. Handouts that describe the goals of fat content,
specific foods to choose and avoid, and how to read and
interpret food labels should be available for distribution.
These are available from a variety of sources. Patients
may be referred to the AHA web site, which offers information about recommended diets as well as recipes. Drug
companies that market cholesterol-lowering medications
often provide free patient information materials that may

The third set of tools involves the pharmacists documentation of interventions and results. If lipids are to be
measured and followed, the use of a monitoring flow
sheet is extremely useful (Fig. 1). Flow sheets may be on
paper files, created on computer spreadsheets, or use special software programs.
Initial demographic data including height should be
collected. The information obtained at each visit should
include weight, exercise, lipid values, drug therapy (if
any), and compliance. If available. other pertinent labs
such as glucose or hemoglobin AlC, liver transaminases,
or measures of renal function should be noted. A comments section is useful to document items such as adverse
drug effects, noncompliance, o r other issues that can affect lipid control.

Communication
The fourth set of tools regards communication with physicians or other primary care providers. Interventions made
by the pharmacist or recommendations to the physician
may be made by telephone, letter, fax, or personal contact,
depending on the practice setting. These communications
are important in both obtaining and maintaining provider
buy-in as well as demonstrating the active role the pharmacist is playing in the care of the patient. In addition,
there is less likelihood for misunderstanding than if all
information is provided by the patient.

Lipid Measurement Devices

Lipid analyzers are not necessarily a needed tool for
providing lipid management services but can be very

Table 1 Cholesterol monitoring tests granted CLIA waived status

System

Manufacturer

Advanced Care
Cholestech LDX

Johnson & Johnson

Cholestech

Accu-Chek InstantPlus
ENA.C.T Total Cholesterol Test
Lifestream Technologies Cholesterol Monitor
Polymer Technology Systems (PTS) MTM
Bioscanner 1000 (for OTC use)

Boehringer Mannheim
ActiMed Laboratories
Lifestream Technologies
Polymer Technology Systems, Inc.

(Adapted from Ref. [31].)

Lipoprotein measured
Cholesterol
Total cholesterol, HDL,
triglycerides, glucose
Cholesterol
Cholesterol
Cholesterol
Cholesterol, HDL

Hyperlipidemia Pharmacy Practice

helpful. They allow the pharmacist to provide information and make recommendations for dietary and drug
therapy at the time of the interaction, instead of having
to schedule another time or attempt to reach patients by
phone. It allows reenforcement of the information
provided at the last visit as the patient can see the results of the intervention, and the implications of adherence or nonadherence to therapy can be demonstrated and discussed, and strategies for improvement can
be presented.
Measuring cholesterol in the practice setting requires
both the equipment and the legal authority to perform
testing. The 1988 Clinical Laboratory Improvement
Amendments (CLIA) established quality standards for accuracy, reliability, and timeliness in all laboratory testing.
Certain devices are considered to be of low complexity
and are therefore regarded as CLIA waived, which means
that the site where they are used must be enrolled in the
CLIA program but that routine on-site visits and monitoring are not required.
The cholesterol measuring devices that are in the CLIA
waived category are listed in Table 1. At this time, the
only waived analyzer that measures total and HDL cholesterol and triglycerides is the Cholestech LDXE. State
law will also need to be followed because some states, for
example, do not permit pharmacists to act as laboratory
directors or to obtain blood via finger stick. Information
about obtaining CLIA certification, a list of waived devices, and contact information for state survey agencies may
be found on the CLIA web site.'301

Although obtaining reimbursement is beyond the scope of

this chapter, a number of studies have tried to assess what
patients will pay or perceive to be the value of provision
of cholesterol monitoring and lipid management. The data
range from assessing the value of a cholesterol level
without attendant counseling to how much patients believe insurance companies should pay for each visit to the
pharmacist where education and medication review and
management are provided.
Project ImPACT is one of few studies that reports
actual billing and reimbursement results. Both patients
and insurers were billed for services. On average, pharmacists billed $28 for counseling services and $27 for
lipid profiles. Seventy-five percent of patients billed paid
an average of $35 per visit, and 53% of third-party payers
paid an average of $30. Reimbursement by third-party
payers was more frequent, however, for lipid profiles than
for counseling.

467

Pharmacist practices in hyperlipidemia management have

been shown to be effective in improving compliance,
adherence to therapy, and LDL lowering. Studies that
establish cost effectiveness are limited and are needed to
support efforts to expand pharmacist involvement and
justify reimbursement.

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Anderson, J.W.; Elam, M.B., et al. Gemfibrozil for the
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Med. 1987, 317, 1237-1245.
I. Shepherd, J.; Cobbe, S.M.; Ford, I.; Isles, C.G.; Lorimer,
A.R.; MacFarlane, P.W., et al. Prevention of coronary heart
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Pearson, T.A.; Reed, J.; Smith, S.C., Jr.; Washington, R.
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When to start cholesterol-lowering therapy i n patients

with coronary heart disease: A statement for healthcare
professionals from the American Hcarl Association Task
Force on Risk Reduction. Circulation 1997, 0.5, I683
1685.
9. Avorn, .I.;Monette, J.; Lacour, A,; Bohn, 1C.L.; Monane,
M.; Mogun, H., et al. Persistence of use of lipid-lowcring
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y~erlipidemiaPharmacy Practice

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N.K.: Testa, M.A.; Saperia, G.M.; Platt, R. Discontinutation of antihyperlipidemic drugs-do rates reported in clinical trials reflect rates in primary care settings'? N. Engl. J.
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11. Pearson, T.A.; Laurora, 1.; Chu, H.; Kafonek, S. The Lipid
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12. Konzem, S.L.; Gray, D.R.; Kashyap, M.L. Effect of pharmaceutical care on optimum colestipol treatment in elderly
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PROFESSIONAL DEVELOPMENT

Steven C. Ebert
Meriter Hospital, Inc., Madison, Wisconsin, U.S.A

INTR

Since the 1980s, the specialty area of infectious diseases

within pharmacy practice has evolved into a distinct
discipline that is directed at providing optimum antimicrobial therapy to patients. The pharmacist is uniquely
qualified to apply therapeutic, pharmacokinetic, and
pharmacodynamic principles to antimicrobial therapy.
These skills serve to complement rather than compete
with the roles of infectious diseases physicians. Infectious
diseases pharmacists are employed in private and teaching
hospitals, clinics, academia, and industry. Literature that
document the positive impact of the infectious diseases
pharmacist on patient outcomes is now being published.

Education and Postgraduate Training

Infectious diseases pharmacists have typically been
awarded either a postbaccalaureate or entry-level Doctor
of Pharmacy degree. In addition, most have completed 2
to 3 years of postdoctoral training that consists of a 1-year
residency in pharmacy practice, followed by either 1 year
in an infectious diseases specialty residency or a 2-year
infectious diseases fellowship. It should be noted, however, that a select number of motivated practitioners have
not completed these postgraduate training programs, but
instead have become proficient in infectious diseases
through on-the-job training.

Pharmacists who have been practicing for more than 3

years and/or have completed postgraduate training may
become certified in pharmacotherapy (BCPS) through the
Board of Pharmaceutical Specialties (BPS). This certification is achieved via examination. In addition, as of the year
2000, BCPS awardees could be granted Added Qualifica-

Encyclopedia of Clinical Pharnzacy

DOI: 10.1081iE-ECP 120006229
Copyright D 2003 by Marcel Dekker, Inc. All rights reserved.

tions in Infectious Diseases Pharmacotherapy by submitting an application to BPS. The application consists of a
portfolio that describes the applicants practice in infectious diseases pharmacotherapy. The portfolio includes[]

1. A letter from applicant requesting review of

portfolio for purpose of granting Added Qualifications in Infectious Diseases Pharmacotherapy.
2. Current curriculum vitae (CV).
3. A detailed summary of each of the following
elements (if not included in CV):
a. Any special training or professional development programs in the area of infectious
diseases pharmacotherapy.
b. Work experience in the area of infectious
diseases pharmacotherapy.
c. Specific professional responsibilities for care
of patients with infectious diseases in outpatient and inpatient settings.
d. Any professional awards, honors, or special
achievements relative to infectious diseases
pharmacotherapy .
e. Bibliography of applicants relevant professional publications.
f. List of applicants past and present research
or other scholarly activities in the area of
infectious diseases pharmacotherapy.
g. Summary of past and current educationalhnservice activities for health care professionals
in infectious diseases pharmacotherapy.
h. List of memberships in professional organizations relative to infectious diseases, with
specific notation of any service or leadership
activities to the organization.
At this time, Board Certification in Pharmacotherapy
with Added Qualifications in Infectious Diseases is a
means for recognizing outstanding practitioners. It is not a
means of licensure or a prerequisite for practicing in the
area of infectious diseases pharmacotherapy.

469

Infectious Diseases Specialty Pharmacy Practice

470

Hsspit

ice

Pharmaceutical care of the hospitalized patient with infection is the most traditional role for infectious diseases
pharmacists. Numerous opportunities for proactive interventions in antimicrobial selection, dosing, route of administration. and monitoring of patients with changing
clinical status make this a popular practice setting for
many individuals.

macists trained in infectious diseases may practice in a

clinical setting that requires not only expertise in antimicrobial therapy, but also other therapeutic areas. For
example, an infectious diseases pharmacist may practice
as a clinical coordinator who is charged with developing
practice areas such as cardiology, nutrition support, etc.,
in addition to antimicrobial management programs. Other
practice sites that require a working knowledge of infectious diseases include clinical pharmacokineticists, critical care pharmacists, and transplant pharmacists. These
practice positions are typically funded 100% by the hospital in which they are located.

Practice solely in infectious diseases

Infectious diseases pharmacists typically practice in a
hospital setting that allows them to devote all their time
to managing antimicrobial therapy. All aspects of infectious diseases pharmacotherapy, including interventions on antimicrobial selection, antimicrobial dosing,
and intravenous-to-oral conversion are the responsibility
of the infectious diseases pharmacist. In addition, the
pharmacist is usually responsible for analyzing new
antimicrobials for formulary inclusion, medication use
evaluations. and antimicrobial restriction or therapeutic
interchange policies.
Some infectious diseases pharmacists may collaborate with infection control practitioners to reduce nosocomial infections and control antimicrobial resistance.
Others may work closely with clinical microbiologists
to design institution-specific susceptibility testing and reporting methods, and to generate periodic antibiotic susceptibility reports.
In hospitals with a significant pharmacy influence on
antimicrobial therapy, it may be impossible for the infectious diseases pharmacist to perform all the functions
described here. Instead, the pharmacist may need to
delegate the responsibility for conducting standardized
antimicrobial protocols (therapeutic interchange. intravenous to oral, aminoglycoside pharmacokinetics) to
other pharmacists, while maintaining accountability for
the quality of these programs.
Although the salary for many hospital pharmacists who
practice exclusively in the area of infectious diseases
comes from the hospital in which they practice, a substantial number are cofunded by hospitals and schools of
pharmacy or medicine.

Combined with other responsibilities

In hospital pharmacy departments with limited resources
or incomplete antimicrobial management programs, phar-

An increasing number of infectious diseases pharmacists

practice in outpatient settings. These individuals usually
practice in one of two areas. One area is in outpatient
clinics, where they are directly involved in patient care.
This is particularly true for pharmacists who specialize in
treatment of patients infected with human immunodeficiency virus (HIV) or other chronic infectious diseases
(e.g., leprosy). Pharmacists take medication histories,
counsel patients about their medications, assess response
to antimicrobial therapy, and make adjustments in therapy, as necessary.
Infectious diseases pharmacists also make valuable
contributions to patient care in the managed care setting. By evaluating antimicrobial prescribing patterns,
creating drug treatment protocols, directing formulary
decisions. and counterdetailing prescribers, infectious
diseases pharmacists help to curtail inappropriate antibiotic prescribing that may lead to increased antibiotic resistance.

a c e u ~ i c Industry
~l
An increasing number of infectious diseases pharmacists
have found a career in the pharmaceutical industry. Some
initially take positions in pharmaceutical sales. Others
may be hired as research associates, where they assist in
the collection and analysis of data for clinical studies.
More often, they are hired as medical science liaisons.
These individuals interact with physician and pharmacist
practitioners, where they provide drug information, grant
support for research and educational efforts, assist in
medication use evaluations, and give in-services to medical and pharmacy staff.
Promotions within industry have lead many of these
pharmacists into advanced positions such as Director of
Medical Affairs. Associate Director for Research, or Associate Director for Education.

Infectious Diseases Specialty Pharmacy Practice

esearch ~rganization
Some infectious diseases pharmacists join contract research organizations. These organizations work primarily
with pharmaceutical companies to test the in vitro activity
of new antimicrobials, assess their efficacy in intro and
animal infection models, and conduct clinical trials. Pharmacists may be hired into positions ranging from researcher to director.

Government
Some infectious diseases pharmacists have been hired into government positions. These individuals direct government-initiated studies, care for patients in clinics, and
formulate policies regarding medication use. Infectious
diseases pharmacists currently hold positions in the Food
and Drug Administration, National Institutes of Health,
and World Health Organization.

Independent Consultant
Many infectious diseases pharmacists devote some time
to work as consultants. In most cases, they serve as ad
hoc consultants for pharmaceutical companies, where
they assess the likely impact of a newer antimicrobial
andlor providing advice on direction of future studies.
They may also educate pharmaceutical sales staff or write
review articles.
Other infectious diseases pharmacists work full time
as consultants. Usually, they are employees of larger
consulting firms that are hired by hospitals or other health
care institutions to detect inefficiencies in process and to
improve financial success.

ICAL PRACTICE SETTl

Hospital Setting

Rounding with an infectious diseases

consult service
Most infectious diseases pharmacists who practice in a
hospital setting round with an infectious diseases consult
service. This service usually consists of an infectious
diseases physician, an infectious diseases medical fellow,
medical students, an infectious diseases pharmacist, and
(possibly) pharmacy students, residents, or fellows. Patients are usually identified through infectious diseases
consults. The pharmacist usually acts to optimize
the antimicrobial regimen by adjusting antibiotic doses

471

and apprising the service members of any imminent drug

interactions or adverse effects. The pharmacist also
monitors patients followed by the service, to assess
therapeutic response and/or adverse events. Finally, the
pharmacist serves as a resource for drug information for
service members.
The advantages of rounding with an infectious diseases
consult service include a sense of teamwork and
camaraderie; the backing of an infectious diseases physician, which means that most recommendations will be
followed; direct interaction with only a limited number of
(infectious diseases) physicians, which will quickly
establish mutual trust and respect; and the potential for
collaboration in research. Disadvantages include limited
patient exposure (usually only patients involved in consults are followed) and, potentially, limited usefulness if
the infectious diseases attending physician is knowledgeable in antimicrobial pharmacology.

Pharmacist-infectious diseases
physician collaboration
Another common practice model for hospital-based
pharmacists is a one-on-one collaboration between an
infectious diseases pharmacist and an infectious diseases
physician. Under this model, the infectious diseases
physician is generally responsible for standard infectious
diseases consults. The pharmacist acts as an extension
of the infectious diseases physicians clinical practice
clinical practice, rather than competition or duplication.
The pharmacist identifies patients in whom antimicrobial
therapy is suboptimal (i.e., wrong drug, wrong dose,
questionable indication, potential for IV-to-oral conversion). After conferral with the infectious diseases physician, an intervention is recommended or implemented.
These interventions usually follow predefined criteria established by the Pharmacy and Therapeutics Committee.
Some advantages of this model are the establishment
of a close relationship between infectious diseases
physicians and pharmacists, the backing of the infectious
diseases service and the Pharmacy and Therapeutics
Committee on interventions, and the potential for
pharmacists to bill for clinical pharmacy services through
a physician provider. Potential disadvantages exist if the
infectious diseases physician and pharmacist do not
interact well.

Independent practice
Under a third practice model in the hospital setting,
infectious diseases physicians and pharmacists conduct
separate services: the physician handles infectious di-

Infectious Diseases Specialty Pharmacy Practice

472

seases consults, and the infectious diseases pharmacist

identifies patients with inappropriate antimicrobial therapy and makes interventions. Under this system, the
Pharmacy and Therapeutics Committee will ideally grant
the pharmacist some authority to automatically order
modifications in therapy. This model is used when
infectious diseases physicians are either unwilling or
unable to become involved in interventions concerning
antimicrobial therapy. A potential disadvantage is the
perceived competition between infectious diseases
physicians and pharmacists for consults. Indeed, the Infectious Diseases Society of America (IDSA) has issued a
statement condemning the independent practice of a
pharmacist to advise physicians on selection of antimicrobial therapy.[21 In hospitals that have limited or no
infectious diseases physician presence, this model may be
the only viable option.

the spectrum of therapy based on culture and susceptibility report^)'^-^] and intravenous-to-oral conversion of
antibiotics[73s1have shown that interventions by pharmacists can reduce costs and lengths of stay without adversely effecting quality of patient care. However, more
research and publications are necessary to fully document the beneficial impact of infectious diseases pharmacist interventions.

MATERIALS USED BY INFECTIOUS

Journals
A number of published journals specifically directed
toward infectious diseases and antimicrobial therapy are
available as resources for infectious diseases pharmacists:

utpatient Settin
As mentioned previously, some infectious diseases
pharmacists have established effective clinical practices
in the outpatient setting. The most common example of
this is the presence of a pharmacist in an HIV clinic. The
myriad of antimicrobial drug interactions and adverse
effects associated with antiretroviral therapy, the need to
periodically assess antiretroviral efficacy, and the considerable potential for noncompliance literally necessitate
the need for a pharmacist in any established HIV clinic.
Infectious diseases pharmacists work with infectious
diseases andlor immunology physicians. Pharmacists conduct medication histories and answer drug information
questions. In some settings, they may act under protocol
to assess patient response to antiretroviral therapy based
on virologic and immunologic measures, and to make
appropriate modifications in therapy.

ECT
ON

ISEASES
T CARE

The original published reports of the impact of infectious

diseases pharmacists interventions on patient outcomes
were limited to therapeutic drug monitoring of aminoglycosides. Therapeutic drug monitoring of aminoglycosides
by pharmacists resulted in more appropriate utilization of
serum aminoglycoside concentrations, more serum concentrations within the therapeutic range, and reduced
nephrotoxicity when compared with monitoring by physicians (Destache et al.).[31
Subsequent reports of the impact of interventions by
infectious diseases pharmacists have focused more on
improving the antimicrobial therapy process. Specifically, reports of antibiotic streamlining (narrowing

Clinical Infectious Diseases-This

journal, formerly
named Reviews of Infectious Diseases, is an official
publication of the IDSA. Articles are primarily directed
at the diagnosis and treatment of infectious diseases,
including clinical trials. Frequently, State of the Art
articles are published that summarize current therapy of
a particular infection. In addition, IDSA guidelines for
the treatment of infectious diseases are published in
this journal.
The Journal of Infectious Diseases-This journal is also
published by IDSA. The contents of this journal are
generally directed at the cellular mechanisms of pathogenesis and immunity of infection. From a pharmacist
practitioner standpoint, it is of less usefulness than
Clinical Infectious Diseases.
Antimicrobial Agents and Chemotherapy-One
of the
official journals of the American Society for Microbiology, this journal focuses on characterizing and quantifying the activity of antimicrobial agents against various pathogens. Many papers are directed at mechanisms
for antimicrobial resistance and activity of newer antimicrobials in vitro. Studies of the efficacy of antimicrobials, as measured via in vitro pharmacokinetic and
animal infection models, are published frequently. Studies of drug treatment in humans are also published, but
less frequently.
Journal of Antimicrobial Chemotherapy-This
British
publication addresses all aspects of infectious diseases
pharmacotherapy and therapeutics. Both American and
European authors contribute to this journal. A review
article at the beginning of each issue addresses a pertinent
clinical issue. Supplements are published regularly that

473

Infectious Diseases Specialty Pharmacy Practice

focus on new antimicrobial agents. More so than other

journals, this journal regularly addresses pharmacokineticlpharmacodynamic issues. Although it is very popular, it occasionally suffers from lack of relevance, in that
position papers are usually European rather than American organizations.
Infectious Diseases Clinics of North America-This
quarterly, hardbound journal focuses on a single infectious disease topic in each issue. Experts in the field of
infectious diseases author state-of-the-art articles that
are useful for review or for teaching purposes. Although
the articles usually do not present breaking information, they are useful in defining current practice in infectious diseases.
Infectious Diseases irz Clinical Practice-This is a very
pragmatic journal with topics that clearly state that this
journal is authored by practitioners, for practitioners.
Although it is not currently referenced in MEDLINE,
this journal offers special insights into practice-related issues that are authored by eminent infectious diseases practitioners.
Journal of Infectious Diseases Phaiwzacotherapy-This
journal, still in its infancy, is the first attempt by clinical
pharmacy practitioners to author a journal devoted entirely to infectious diseases pharmacotherapy. It is also
not referenced in MEDLINE. Although it has suffered
from identity crisis, the articles are excellent. well
referenced, and pertinent to current practice. Hopefully,
this journal will continue to grow in stature over the next
few years.
In addition to those described here, a number of
journals devoted to internal medicine andlor pharmacology topics will from time to time publish articles concerning infectious diseases. They are not discussed further
in this article.

the text, it is well written and is a useful resource for those

looking for information on antimicrobial pharmacokinetics, interactions, and adverse effects.
Kucers, Crowe, Grayson, and Hoy, eds., The Use of
Antibiotics (Butterworth-Heinemann, Oxford, 1997)Kucers remains the standard as a reference text for
antimicrobial pharmacology. Arranged by drug classes,
this text describes the clinical pharmacology of all known
antimicrobials, and has the advantage of its long
publication history to include classic references in
antimicrobial pharmacokinetics, adverse effects, and
interactions. Because of the evolving nature of antimicrobial resistance, the sections on in vitro activity are
often dated and of limited usefulness when comparing
antibiotics.
Yu, Merigan, and Barriere, eds., Antimicrobial Therapy and Vaccines (Williams and Wilkins, Baltimore,
1998)-This text, first published in 1998, is a laudable
attempt to create a comprehensive reference of pathogenic organisms and antimicrobials. Unlike Principles
and Practice of Infectious Diseases, the text does not
specifically address infectious diseases syndromes.
Approximately half of the chapter authors are infectious
diseases pharmacists. Chapters are addressed by pathogen and by corresponding therapeutic agent(s). They are
relatively short but extremely well referenced and
clinically relevant. Each chapter devoted to a pathogen
is divided into sections on general description, microbiology. susceptibility, and treatment of infections
caused by that pathogen. Chapters on antimicrobial
agents are divided into sections on chemistry, antimicrobial activity, pharmacodynamics, pharmacokinetics,
and adverse effects. Overall, this is a very useful text.
Hopefully, it will continue to a second (and subsequent)
edition.

Guidelines

Although they are republished less frequently than

journals and therefore may contain dated material, some
books and texts have stood the test of time and remain
valuable resources:
Mandell, Douglas, and Bennett, eds., Principles and
Practice of Infectious Diseases (Churchill Livingstone,
Philadelphia, 2000)-This bible of infectious diseases
is a must for every infectious diseases practitioners
bookshelf. This book addresses virtually all infectious
diseases topics from both a disease- and a pathogenrelated perspective. Although the antimicrobial pharmacology component represents only a small portion of

Guidelines or consensus statements are important for infectious diseases pharmacists because they identify the
state of the art on paper, which creates a template by
which they may conduct their practice. For the most part,
pharmacists are relatively content to follow and adhere to
clinical guidelines, as long as they are logical and well
written. Unfortunately, many guidelines written by physicians address diagnosis and patient assessment much
more than the specifics of drug therapy, an area that is of
outmost importance to infectious diseases pharmacists.
Nevertheless, these guidelines are invaluable for pharmacists who seek reinforcement when developing treatment protocols for their own institutions.

474

Infectious Diseases Specialty Pharmacy Practice

Infectious Diseases Society of America (IDSA)-The

IDSA is the single most common source of guidelines for
treatment of infectious diseases in the United States.
These guidelines are created largely on an ad hoc basis
and are published in Clinical Infectious Diseases.
Examples of such guidelines include treatment of community-acquired pneumonia, urinary tract infections, and
febrile neutropenia. Unfortunately, no systematic process
for generating and routinely updating these guidelines
appears to be in place.
Centers f o r Disease Control and Prevention (CDC)The CDC has begun to exert itself in the area of treatment
guidelines for infectious diseases.[] Well known for their
reports and recommendations that are published in
Morbidity and Mortality Weekly Report, the CDC has
now also issued guidelines for treatment of communityacquired pneumonia. Although these guidelines are
generally more conservative than those issued by other
groups, they do carry the weight of the CDC and the U.S.
government. Hopefully, the issuance of guidelines by the
CDC will continue.
American Thoracic Society (ATSj-The
ATS has
issued guidelines for the treatment of community- and
hospital-acquired pneumonia. These guidelines have also
proven valuable as a reference point for clinicians want to
establish treatment guidelines in their own institution.
Although ATS guidelines carry considerable political
influence, they are typically more consensus driven than
evidence based in nature.

Other organizations-Other organizations may occasionally publish guidelines for the use of antimicrobials in
selected clinical settings. For example, the American
Society of Health-System Pharmacists published guidelines for surgical and nonsurgical prophylaxis in 1999.
When such guidelines are published, most infectious
diseases pharmacists will obtain them and use them as a
resource. However, the sporadic publication of guidelines
from these sources means that practitioners are often left
without specific guidance in many therapeutic areas.

ET

A number of professional societies exist that are either

entirely devoted to infectious diseases or support subgroups
directed toward infectious diseases. Infectious diseases
pharmacists are active members of all the organizations.

Society of Infectious Diseases Pharmacists (SIDP)SIDP, formed in 1990, is the only organization entirely
devoted to practice and research by infectious diseases
pharmacists. Currently, more than 400 infectious diseases
pharmacists are members of SIDP. An elected Board of
Directors and active standing committees conduct the
majority of SIDPs business. SIDP provides grants to
members to conduct research, and also awards funds to
support three infectious diseases residencies annually.
SIDP also cosponsors two to three educational symposia
with other societies each year.
A 1-day annual meeting is held in conjunction with
ICAAC (see below). In addition, members receive a
quarterly newsletter and may visit SIDPs web site
(www .sidp.org).
Interscience Conference f o r Antimicrobial Agents and
Chemotherapy (1CAAC)-The annual meeting, sponsored
by the American Society for Microbiology (ASM), is the
largest meeting devoted to infectious diseases in the
world. Infectious diseases physicians and pharmacists, as
well as microbiologists and infection control practitioners,
comprise the majority of ICAAC attendees. More than
15,000 people gather at ICAAC to review the most recent
research on antimicrobials and attend state-of-the-art
symposia. The sheer volume of information presented at
this meeting makes time management a priority. Numerous infectious diseases pharmacists attend this meeting
every year and are able to network over the 4-day meeting.
Infectious Diseases Society of America (IDSA)-IDSA
is an organization primarily composed of infectious
diseases physicians. However, more than 50 infectious
diseases pharmacists are members of IDSA. Topics at
IDSAs annual meeting parallel the content of their two
journals, Journal of Infectious Diseases and Clinical
Infectious Diseases, and include cellular and biochemical
mechanisms of infectious diseases, and the epidemiology,
diagnosis, and management of infectious diseases. The
limited presence of infectious diseases pharmacists at
IDSA makes networking more difficult.
International Society of Antiinfective Pharmacology
(ISAPj-ISAP is a small but influential organization of
infectious diseases physicians and pharmacologists whose
focus is infectious diseases pharmacokineticslpharmacodynamics. The society is truly international in scope, with
members from the United States, Canada, and Europe.
ISAPs 1-day annual meeting is held immediately after
ICAAC and consists of state-of-the-art lectures on current
concepts in antimicrobial pharmacodynamics. The timing
of the ISAP meeting and its relatively low profile limit
the number of infectious diseases pharmacists that attend

475

Infectious Diseases Specialty Pharmacy Practice

this meeting, but those who do attend remain avid supporters of ISAP.
American College of Clinical Pharmacy (ACCP)-The
ACCP is an organization devoted to the promotion of
clinical pharmacy practice and research. ACCP holds two
meetings annually. The content of material presented at
these meetings spans the scope of clinical pharmacy
practice. However, ACCP has created specialized practice
and research networks (PRNs), one of which focuses on
infectious diseases. For an additional $10, an ACCP
member can join a PRN. PRN members hold business and
scientific sessions at ACCP meetings, which allows for
networking among members. ACCP also supports PRN
listservs on its web site. Finally, ACCP supports a personnel placement service at its fall meeting, where members can recruit residents and fellows.
International Conference of Chemotherapy (ICC)The ICC is a biannual conference that is similar in size
and scope to ICAAC, but is usually held outside the
United States. Although the content is excellent, the
travel, registration, and housing expenses make this
meeting cost prohibitive for most American infectious
diseases pharmacists. Those who do attend enjoy the
opportunity to interact with practitioners and researchers
from around the globe.
International Conference on Macrolides, Azalides,
Streptogramins, and Ketolides (ICMASK0)-ICMASKO
is a biannual conference that is attended primarily by
infectious diseases researchers who present their research
on macrolides, azalides, streptogramins, and ketolides.
This is a relatively small, intimate meeting that allows for
networking for those in attendance.
American Society of Health-System Plzarmacists
(ASHP) Midyear Clinical Meeting-ASHP s midyear
clinical meeting is one of the largest annual meetings of
pharmacists in the world. The scope of topics presented at
the meeting is very diverse, ranging from clinical topics to
reimbursement issues. No specific subgroup of pharmacists devoted to infectious diseases exists within the
ASHP. However, numerous infectious diseases satellite
symposia and research papers are presented during the
meeting. Many infectious diseases pharmacists use this
meeting to recruit residents and fellows.
International Conference on Retroviruses-The International Conference on Retroviruses focuses specifically
on the treatment of patients with HIV infection. This
conference attracts pharmacists who care for these
patients. A variety of papers dealing with new antire-

troviral agents and combinations are presented, in

addition to presentations outlining the best means for
caring for these patients. Unfortunately, infectious diseases pharmacists currently are not fully recognized
at this meeting, and problems with registration have
occurred. Many other pharmacist societies are lobbying to
correct this problem.

industry C~nsultantsh~ps
From time to time, infectious diseases pharmacists are
invited to serve as consultants at small meetings held by
pharmaceutical manufacturers. Typically, 6 to 12 consultants are invited to give their opinions about the
likelihood of success of a new antimicrobial, or to suggest
new marketing or research strategies. These meetings
serve an additional purpose in that they allow an additional opportunity for interaction and networking between the pharmacists in attendance.

1. Board of Pharmaceutical Specialties. Statement #9903, Added Qualifications for Infectious Diseases; March 6, 1999.
2. Infectious Diseases Society of America Hospital pharmacists and infectious diseases specialists. Clin. Infect. Dis.
1997, 25. 802.
3. Destache. C.J.: Meyer, S.K.; Bittner, M.J.; Hermann, K.G.
Impact of a clinical pharmacokinetic service on patients
treated with aminoglycosides: A cost-benefit analysis.
Ther. Drug Monk 1990, 12, 419-426.
4. Gentry, C.A.; Greenfield, R.A.; Slater, L.N.; Wack, W.;
Huycke, M.M. Outcomes of an antimicrobial teaching
program in a teaching hospital. Am. J. Health-Syst. Pharm.
2000, 57. 268-274.
5 . Berman, J.R.; Zaran, F.K.; Rybak. M.J. Pharmacy-based
antimicrobial monitoring service. Am. J. Hosp. Pharm.
1992, 49, 1701-1706.
6. Briceland, L.L.; Lesar, T.S.; Lomaestro, B.M.; Lombardi,
T.P.; Gailey, R.A.; Kowalski, S.F. Streamlining antimicrobial therapy through pharmacists review of order
sheets. Am. J. Hosp. Pharm. 1989, 46. 1376-1380.
7. Paladino, J.A.; Sperry, H.E.; Backes, J.M.; Gelber, J.A.;
Serrianne, D.J.; Cumbo, T.J.; Schentag, J.J. Clinical and
economic evaluation of oral ciprofloxacin after an abbreviared course of intravenous antibiotics. Am. J. Med.
1991, 91, 460-472.
8. Ramirez, J.A.; Vargas, S.; Ritter, 6 . : Brier, M.E.; Wright,
A,; Smith. S.; Newman, D.; Burke, J.: Mushtaq, M.; Huang,
A. Early switch from intravenous to oral antibiotics and
early hospital discharge: A prospective observational study
of 200 consecutive patients with comminuty-acquired
pneumonia. Arch. Intern. Med. 1999, 159, 2449-2454.
9. www.cdc.gov.

PROFESSIONAL ORGANIZATIONS

lnstitute for Safe Medication Practices, Huntington Valley,

Pennsylvania, U.S.A.

CTI

The Institute for Safe Medication Practices (ISMP) is a

nonprofit organization devoted entirely to safe medication
use and to the prevention of medication errors. A broadbased and interdisciplinary organization, ISMP aims to
provide impartial, timely, and accurate medication safety
information at all times. As an independent watchdog
organization, ISMP receives no advertising revenues and
depends entirely on volunteer efforts, educational project,
grants, and donations to pursue its work. ISMPs work has
been acknowledged and honored by a number of organizations worldwide. For example, in 2000 ISMP received
the prestigious Award of Honor from the American Hospital Association (AHA). In addition, in 1998 the Institute
received the highly regarded Pinnacle Award from the
American Pharmaceutical Association (APhA) and the
Healthcare Quality Alliance (HQA).

ISMPs work, which focuses primarily on improving the

safety of medication distribution and use, naming, packaging, and labeling, falls into five key areas. These areas
are knowledge, analysis, education, cooperation, and communication. All efforts are built on a non-punitive approach and systems-based solutions.

itiat ives
e

ISMPs mission is:

To continually expand knowledge about medication

errors and prevention methods through system analysis
in an interdisciplinary and cooperative manner.
To collaboratively develop and implement effective
error-prevention strategies to reduce the risk of medication errors.
To educate healthcare policymakers about legislative and regulatory steps that can help prevent medication errors.
To communicate broadly and to educate healthcare
professionals and the public about the nature of medication errors, how to prevent them, and how to manage errors that do occur.
To provide professional support for healthcare practitioners in preventing and handling medication errors.

476

Independent review of all errors reported to the USPISMP Medication Errors Reporting Program (MERP)
and acting partner in the FDAs MedWatch Program.
Comprehensive collectiodanalysis of error information
through the organizations global information-sharing
network.
Original and impartial research and practitioner surveys on medication errors and prevention.

P Initiatives
Comprehensive use of failure mode and effects analysis (FMEA) to learn where or when errors are most
likely to occur and to help prevent them.
A thorough review process, using an innovative computer software program, to study and prevent product
name- and packaging-related errors.
Site visits and confidential consultations in various
healthcare delivery settings and throughout the healthcare industry.
A wholly owned subsidiary called Medical Error Recognition and Revision Strategies (Med-E.R.R.S.@)>
which works confidentially with pharmaceutical companies to predict error potential and thereby avoid
problems that might stem from proposed drug names,
labels, and packaging.

Encyclopedia of Clinical P h a m a c y
DOI: 10.1081E-ECP 120006207
Copyright C 2003 by Marcel Dekker, Inc. All rights reserved.

477

Institute for Safe ~ e d i c a ~Practices

io~
8

ISMP provides the Sollowing products and services that

are targeted to healthcare professionals, pharmaceutical
industry, insurance industry, and regulatory agencies:
Slidc programs, CD-ROMs, posters, books, and videotapes on mcdicaiion safety including such topics as
Failure Mode and Effects Analysis (FMEA); timely
and accurate educational sessions and conferences,
slide programs, and presentations.
Knowledgeable and articulatc speakers including nurses, pharmacists, and physicians.
Frcc, Web-based access to archived issues of the biweekly ISMI Medication Sufety Alert! newsletter.
Safe Medication Managemcnt Fellowship that provides postgraduate training to healthcare practitioners
in safe medication management.

Official partnership in the U.S. Food and Drug

Administrations (FDA) MedWatch program.
Collaborative work toward error prevention with the
American Hospital Association (AHA), the Joint Commission on Accrcditation of Healthcare Organizations
(JCAHO), the National Coordinating council on Mcdication Error Reporting and Prevcntion (NCCMERP),
the National Patient Safety Foundation (NPSF), the
United States Pharmacopeia (USP), and dozens of
othcr consumer and professional organizations.
Highly effective educational efforts with legislative
and regulatory bodies to improve the safety of
medication use.

ISMP Medication Safety Alert!-the

nations only
biweekly. .publication that reaches nearly every U.S.
hospital and tens of thousands of healthcare professional with warnings about medication errors and practical prevention strategies.
Special electronic and dircct mail hazard warnings
targeted to healthcare professionals.
Scholarly and practical articles and continuing education columns that reach practitioners in virtually
every healthcare field.
Wcb site with timely and accurate information on errors and prevention recommendations for healthcare
professionals and consumers.
Media relations campaigns that reach millions of
hcalthcare professionals and the public evcry month
by placing crror-prevention information in healthcare
publications and with the nations most prestigious
news organizaiions.
Contact I ~ ~ Q rMartin
~ ~S. tGoldstein,
~ ~ ~ Director
:
of
Program Development, Institute for Safe Medication
Practices, 1800 Ryberry Road, Huntingdon Valley, PA
19006, 2 15.947.7797, mgoldstein @ isrnp.org.

Institute for Safe Medication Practiccs; www.Ismp.org.

ISMP, Medicatian Safety Alert! Huntington Valley, Pennsylvania.

PROFESSIONAL ORGANIZATIONS

st
Maria-JosC Otero
Alfonso Dominguez-Gil
Hospital Universitario de Salamanca, Salamanca, Spain

The Institute for Safe Medication Practices-Spain

(ISMP-Spain)
is an independent, nonprofit Spanish
organization committed to the prevention of medicationsystem errors and adverse drug events.
Called lnstituto para el Uso Seguro de 10s Medicamentos in Spanish, the ISMP-Spain was established in
Salamanca in October 1999, at the Clinic Hospital of the
University of Salamanca. It is an interdisciplinary organization, currently under the direction of Alfonso
Dominguez-Gil and Maria-JosC Otero.
As an independent organization, ISMP-Spain
depends upon volunteer efforts, grants, and donations. It
works in cooperation with healthcare practitioners, professional organizations, the pharmaceutical industry, and
the government in an effort to enhance patient safety. The
ISMP-Spain is also a partner of the ISMP-U.S.A.,
which has agreed to provide a full range of logistic and
scientific support for ISMP-Spain, including consultative support and access to its resources and published
recommendations for use in error prevention.

MISSION
It is the mission of ISMP-Spain to enhance the safety of
the medication-use system and to improve the quality of
patient healthcare. The most important goal is to reduce
the risk of medication errors and preventable adverse
drug events.

Specific objectives of ISMP-Spain

0

478

include:

To maintain a national medication error reporting

program to collect observations and experiences of
healthcare practitioners and to analyze this information with a systems approach in order to draw valid

conclusions. This program shares data with the

ISMP-U.S.A. and is important for the exchange of
information and the coordination of efforts in the
prevention of medication-system errors worldwide.
To increase awareness of the importance of medication
errors among healthcare professionals, institutions,
organizations, the pharmaceutical industry, the patients themselves, and throughout the entire healthcare
system, and to build a safety culture of commitment to
medication error reporting and prevention.
To develop recommendations and effective strategies
for preventing medication errors and reducing adverse
drug events and to educate healthcare professionals
and patients to ensure that these recommendations and
practices are implemented appropriately.

MEDICATION ERRORS
RTING PROGRAM
The key to reducing medication errors lies in learning
effectively from failures. Since its founding in October
1999, ISMP-Spain has maintained a national notification error reporting program. The principal objective of
this program is to obtain information on medication errors
and their causes in order to establish and transmit
practical recommendations to prevent the recurrence of
the errors.
This program has three main characteristics: it is voluntary, confidential, and independent. It collects observations and experiences concerning those potential or
actual medication errors that healthcare professionals
voluntarily report. The information is independently analyzed, with no conflicts of interests nor administrative
pressure, and all information is treated confidentially.
Healthcare professionals can either complete a report
form or contact the ISMP-Spain directly by e-mail, fax,
or telephone to report medication errors with complete
confidentiality. The types of medication errors submitted
include confusion over look-alike or sound-alike drug
names, ambiguity or similarity in packaging or labeling,
Encyclopedia of Clinical Pharmacy
DOI: 10.1081E-ECP 120006373
Copyright 0 2003 by Marcel Dekker, Inc. All rights reserved.

479

misintcrpretatioii of handwritten orders, errors in prescribing and monitoring, or errors in drug administration.
ISMP-Spain carcfully reviews and analyzes all reported errors, and depending on the characteristics, sends
a copy of the report to the Spanish Medicines Agency
(AEM) and to thc pharmaceutical companies whose
products are mentioned in the reports. This information
is also shared with the IS
ISMP-Spain publishes information about submitted
reports on their wcb site www.usal.cs/ismp and includes
safety recommendations designed to help reduce the probability of such errors recurring. The goal is to make this
information readily availablc to healthcare profcssionals.

It is the belief of TSMP-Spain that the first step in the

long road to reducing adversc drug events is getting
everyone to recognize this problem and t o become
committed to combating it. To achieve this goal it will
ry to effectively quantify the extent and cost of
this problem on a national basis. Thc next step would then
be to identify solutions appropriatc for the Spanish
healthcare system, solutions that will lead to the recation errors. For this reason: a key ini, Spain is to carry out and to promote
rcscarch on the incidcnce, nature, and cause of adverse
drug cvents in diffcrcnt settings, as well as their impact
on patients and healthcare costs. This effort will compile
important reference material to help improve safety in
Spanish healthcare.

The education and dissemination of information is

another primary ob.jective of TSMP-Spain: If everyone
understands the nature and causes of medication errors,
there is a much greater possibility of improving patient
safety. In this sense, TSMP-Spain
makes educational
prcscntations and holds conferences at healthcare professional meetings to provide information about adverse
drug events. ISMP-Spain also publishes opinion articles
and practical articles in Spanish healthcare journals in
an effort to broadly disseminate a culture of safety and
error prevention.
Another important goal of ISMP-Spain is to encourage the development of local medication error reporting
and analysis systems in individual healthcare organizations. TSMP-Spain has coordinated a project with the
Spanish Society of Hospital Pharmacy to creatc a standard
terminology and cl ification system of medication
errors so that healthcare organizations can design databascs and analyze medication error reports using the
same system.

UT
TSMP-Spain believes in the importance of coordinating
efforts to enhance patient safety in countries all over the
world. It is open to the creation of a work platform in
Europe and also to cooperating with Spanish-speaking
countries with any initiatives they may undertake to
improve their medication systems.

Institute o f Medicine, Washington, District o f Columbia, U.S.A.

INT
The Institute of Medicine (TOM) was chartered by the
National Academy of Sciences in 1970 to improve the
health of the American people and peoples of the world
by advancing the health sciences and by providing
analysis of important issues in health and health policy
for government, the professions, and the public and
private sectors. The Institute is an independent, nongovernmental organization. It carries out its work largely
through committees of pro bono experts who employ an
evidence-based deliberative process to produce scientifically valid nonpartisan reports. Studies originate in several ways: by Congress mandating that an Executive
Branch agency contract with the IOM; by direct request of
Executive Branch agencies, foundations, or other private
organizations; or as self-initiated projects when the
Institute determines that an important or highly sensitive
issue might not be the subject of a request from an outside
organization. In addition to committee studies, IOM plays
a unique convening role by sponsoring workshops, roundtables, symposiums, forums, and other activities that
enable parties on all sides of an issue to come together
and discuss problems and solutions in a neutral, unbiased setting.
The Institute also has an honorific function. Each year
it elects 60 regular members, five senior members, and
five foreign associates. Elected members include distinguished individuals whose expertise and leadership cover
the broad range of biomedical sciences, public health,
nutrition, environmental sciences, and social and community medicine, as well as pharmacy, the development
of new drugs and biologics, and vaccine and drug safety.
The Institutes charter stipulates that at least one-quarter
of IOM members be from professions other than those
primarily concerned with medicine and health. Thus, the
membership includes leading ethicists, economists, and
social and behavioral scientists, among others.

480

The Institutes portfolio of activities is extensive, ranging

from issues of scientific integrity to the future of specific
areas of health sciences research. The Institute has
undertaken studies on the processes of innovation, including new drug, vaccine, and biologics development.
Its Roundtable for the Development of Drugs and
Vaccines Against AIDS was an important example of
IOMs ability to convene disparate opinions around important issues. In this case, the roundtable included representatives of the National Institutes of Health, the
Food and Drug Administration, the pharmaceutical industry, AIDS activists, and other interested parties. Other
roundtables have considered such issues as the development of drugs for new and emerging infections, antibiotic resistance, and the development of biologics
and devices.
The Institutes studies have had a profound effect on
public health. The range of topics that have been the
subject of TOM studies is wide and varied. Some examples follow:
In addition to recommending priorities for new vaccine
development, IOM committees have also provided
analysis and advice regarding complications associated
with vaccines, barriers to immunization, immunization
finance, and appropriate uses of vaccines.
An IOM committee examined the role of women in
clinical trials-a
complicated issue involving scientists, industry, and ethicists who evaluated the participation of women, particularly women of childbearing age, in drug trials.
The 1999 report entitled To Err is Human: Building a
Safer Health Care System emphasized that medication
errors were an important contributor to morbidity and
mortality. Yet this committee also noted that the
elimination of such errors will require a comprehen-

Encyclopedia of Clinical Pharmacy

DOI: 10.1081E-ECP 120006290
Copyright 0 2003 by Marcel Dekker, Inc. All rights reserved.

Institute of Medicine

sive systematic approach involving physicians, nurses,

hospitals, pharmacists, patients, and others in health
care working together. Better information technology,
computerized data entry, and nonpunitive reporting of
near misses were a few of the elements recommended
as an approach to accomplish this goal.
Substance abuse has been the subject of several IOM
studies, which have covered a whole host of issues
related to the topic, including federal regulation of
methadone treatment, the development of medications
for the treatment of opiate and cocaine additions, and
community-based research to find better ways to treat
people who abuse drugs.
Fluid replacement has been examined both in relation
to conditions such as heat stress and when used to
resuscitate and treat combat casualties and civilian
injuries.
The FDA Advisory Committee process and other FDA
roles and functions have been the subject of IOM studies that have led to significant changes in the agencys function. In one important study, Halcion: A n
Independent Assessment of Safety and Efficacy Data,
an IOM committee addressed the difficult problem of
the criteria and procedures for withdrawing a previously approved drug from the market.
In 1997, the report Pharmacokinetics and Drug Interactions in the Elderly and Special Issues in Elderly
African-American Populations considered the special
challenges confronted by proper use of agents in these
groups.
A landmark 1988 report, The Future of Public Health
(soon to be updated), identified many of the critical
challenges to education, practice, and applications of
public health. In 1998, the Institute helped develop the
prototype leading indicators for Healthy People
2010, the nations blueprint for prevention. The importance of community organization and partnerships
in furthering the public health has been underscored by
a number of other Institute reports.
A series of studies on health and behavior and the role
of the social and behavioral sciences in health have
had important implications for public health, as well as
for other aspects of medicine. The 1992 report Emerging Infections: Microbial Threats to Health in the
United States was among the earliest warnings with

481

regard to this issue and also focused on the development of antibiotic-resistant organisms. It has been
followed by a number of efforts in both public and
private sectors to respond to these threats.
The Institute is also responsible for establishing dietary reference intakes-quantitative
estimates of nutrient intakes to be used for planning and assessing
diets for healthy people-which update and replace the
recommended dietary allowances.
The 1986 report Confronting AIDS: Direction f o r
Public Health, Health Care, and Research was an
IOM-initiated project that addressed seriously what
had been to that time a largely ignored epidemic.
Subsequent reports have addressed needle exchange,
the behavioral and mental health aspects of HIV infection and AIDS, and the prevention of perinatal
transmission of HIV. The most recent IOM report
on the subject, No Time to Lose: Getting More from
HIV Prevention, provides a comprehensive review of
current HIV-prevention efforts in the United States,
as well as a framework for future activities.
Several studies have focused on environmental issues,
including the concept of environmental justice, environmental and occupational education and training
in medicine and nursing, and the role of environmental
factors in illness (e.g., asthma).
Among the reports issued by the Institute on tobacco
and tobacco control, the 1994 report, Growing Up
Tobacco Free: Preventing Nicotine Addiction in
Children and Youths, was particularly influential in
establishing national policy.
The Institute also conducts a significant program in
international health, including efforts to control hepatitis and diarrheal diseases in the Middle East, that
are being conducted through collaborations involving
American, Israeli, Egyptian, and Palestinian scientists.
More recently, Jordan has joined the academies from
these countries in addressing problems of water conservation and micronutrients in the region.
The full text of Institute of Medicine publications is
available on-line at the National Academy Press web site,
www.nap.edu. Additional information about the Institute
and its activities, as well as a list of all publications, can
be found at www.iom.edu.

PHARMACY PRACTICE ISSUES

University of Arizona, Tucson, Arizona, U.S.A.

Big Sur, California, U.S.A.

INT

Although the terminology "integrative medicine" has

been used synonymously with such terms as complementary, alternative, and unconventional medicine, it in
fact represents the emergence of a totally new model of
healthcare delivery."-31 In the broadest sense, integrative
medicine seeks to combine the best therapies of Western
(conventional) medicine with the best alternative modalities to provide each individual patient with an optimal
treatment plan for their specific ~ituation.'~]
In addition,
this synergistic approach has as its foundation an assumption of the innate healing power of each human organism
and a belief in the centrality of the healing relationship
between doctor and patient."]

Practitioners of conventional medicine are justifiably

proud of the achievements of their profession, showcased by the pharmacological, radiological, and surgical
advances of the 20th century. Fundamental reliance on
such technologies, however, has led to the dismissal of
numerous therapies developed outside the conventional
medical model.[51 Exclusionary attitudes escalated when
studies revealed that an estimated one-third of the
U.S. population was using complementary and alternative modalitie~.[~-~I
The result was increasing divisiveness between proponents and opponents of unconventional therapies, even though practitioners on both sides
had received identical training during their medical
education."'.' 'I
Perhaps the greatest controversy of interest to the pharmacist has involved the increasing use of botanicals and
nutritional supplements. Despite objections from conventional physicians and pharmacists, the U S . Congress
482

responded to pressure from the public and nutraceutical

industry by passing the Dietary Supplement Health and
Education Act of 1994 to ensure broad access to these
products."21 As further evidence of governmental intervention, the National Institutes of Health (NIH) created
the National Center for Complementary and Alternative
Medicine (NCCAM) and provided a current budget of
$68.3 m i l l i ~ n . " ~More
]
recently, the Office of Dietary
Supplements (ODS) within the NIH has established four
centers for phytomedicinal research, ensuring that selected
botanicals will be evaluated by the same or similar processes expected for prescription medication^."^^
Why is the public turning toward complementary and
alternative medicine (CAM)? Surveys showing that CAM
use tends to be higher in patients with diseases often inadequately treated by conventional therapies (e.g., arthritis,
This may seem to suggest an inherent
dissatisfaction with conventional medicine. However, studies specifically addressing this issue have demonstrated
that patients are actually turning toward CAM in keeping
with their individual philosophical values and belief syst e m ~ . [ ' ~ " *Reasons
]
for patient use not withstanding, it
would be beneficial for conventional practitioners to
investigate the attraction of CAM, and how it can be
used to strengthen and enhance their individual practices. This perspective appears even more appealing in
light of the fact that public interest and usage of CAM
continues to
Although the breadth of CAM therapies range from
traditional systems developed in other cultures (e.g., traditional Chinese medicine [TCM]) to recently developed
practices loosely based on science (e.g., functional medicine), most tend to share certain underlying perspect i v e ~ . [ ' ~ ~Such
* ' ~ philosophies include belief in the interconnectedness of mind and body, preference for innate
rather than artificial (e.g., pharmaceutical) sources of
healing. and recognition of an ultimate meaning underlying each individual's illness.[*'] Consequently, many
Encjclopedia of Clinical Pharmacy
DOI: 10.1081E-ECP 120006402
Copyright 0 2003 by Marcel Dekker. Inc. All nghts reserved.

Integrative Medicine

CAM practitioners spend far more time with their patients

than conventional practitioners, listening attentively and
attempting to truly understand what the patient wants and
who they are as an individual.[*l] A patient can thus leave
a session with a feeling of empowerment and a belief that
they can be well again.

DEW
The basic tenet of integrative medicine is that it neither
rejects conventional medicine nor uncritically accepts
CAM.] Just as various alternative practices are as yet
unproven and some do carry significant risk, practitioners
of integrative medicine recognize that it is also important
to be just as analytical of conventional medicine. For
example, the fact that adverse reactions to prescription
medications represent between the fourth to sixth leading
cause of inpatient deaths came as a shock to many in the
healthcare field.12] An Institute of Medicine survey found
iatrogenic illnesses to be the eighth leading cause of
death, exceeding the deaths attributable to motor vehicle
accidents, breast cancer, and acquired immunodeficiency
syndrome.[233241
Consequently, in weighing the risks inherent to any therapy, conventional or CAM, the integrative practitioner seeks the least invasive, least toxic, and
least costly interventions whenever possible.
Another cornerstone of the integrative model is the
assertion that healing optimally occurs when all factors
that influence health, as well as illness, are addressed.
Beyond the patients physical condition lie the mental,
emotional, and spiritual influences on quality and duration of life.L232o1
Sir William Osler is quoted as saying,
It is more important to know what sort of patient has a
disease than what sort of disease a patient has.21 Whether searching for relief from illness or for promotion of
health, patients choosing the integrative model are offered more tools than just drugs or surgery.] The most
common recommendations made are modification in diet
and increase in level of physical activity. Stress reduction
techniques (e.g., biofeedback, yoga, tai chi) are encouraged to be used in place of negative coping activities
(e.g., tobacco, alcohol, recreational drugs) during difficult
times. Positive coping skills can also be based in spiritual
practices such as prayer, church attendance, meditation,
or even such common activities as nature walks. Community involvement including volunteer work can also
help to increase an individuals positive outlook. These
cornerstones of a healthy life (good nutrition, physical
activity, and stress reduction) are considered the primary
means by which illness can be both prevented and treated.
Health, therefore, becomes more than just the absence of

483

disease. Other tools that are available to the integrative

medicine practitioner include hypnosis, guided imagery,
TCM, Ayurvedic medicine, homeopathy, osteopathy,
chiropractic treatments, and a host of others. Discussion
of such complex systems is beyond the scope of this
article. [251
The actual foundation upon which the integrative model rests is the creation of a deeply respectful and understanding relationship between patient and practitioner.[l 261 The practitioner recognizes that they are merely
the means by which patients can discover, or actually
rediscover, their innate capacity to restore health. This
process begins with asking open-ended questions and
listening patiently to the answers with a nonjudgmental
attitude.1211 Patients are allowed to make choices about
therapies or lifestyle changes that are consistent with their
values and philosophical beliefs, which reconfirms one of
the primary reasons they are using CAM.[17.261
Medical
decision making is shared rather than dictated by informing the patient of all possible alternatives, whether conventional or CAM. This requires that the practitioner
becomes knowledgeable about a wide array of potential
interventions that may be useful to their patient, as well as
which interventions should be avoided.[261
Essential to a partnership in medical decision making
is the necessity that each patient realigns his or her own
approach toward health and the healthcare system. Currently, our Western culture advertises and promotes poor
choices in lifestyle that ultimately result in burgeoning
healthcare expenditures. Fundamental to this new paradigm of healthcare is the requirement that individuals
take responsibility for their own wellness, making healthy
choices concerning nutrition, physical activity, and response to stressful situations.
Finally, it is recognized that to ensure patient trust
and compliance, health professionals must develop and
model a healthy lifestyle for themselves. To this end,
integrative practitioners are encouraged to examine
and remedy the indoctrination of the current system
that rewards the overworked, driven, and harried healthcare professional.
As part of the analysis and critique of both CAM and
conventional modalities, integrative medicine practitioners search for accurate information in texts, primary
literature, and the Internet to counsel their patients on the
relative efficacy, safety, and appropriate use of these therapies. To ensure validity of research findings, it is becoming increasingly evident that other methodologies, in
addition to the randomized controlled trial, need to be
conceived and completed to fully evaluate these unconventional therapies as well as the integrative medical
model itself.

484

Integrative Medicine

CLIN~CALMODEL
The past 10 years have witnessed the emergence of a large
number and wide variety of integrative clinical models.
Configurations have ranged from providing mostly conventional therapies with a smattering of complementary
modalities to groups of alternative practitioners simply
sharing both office space and patient populations. A feasible model that most accurately reflects the definition of
integrative medicine incorporates practitioners who have
been trained in both conventional and alternative therapeutic modalities. In support of this approach, a patient
survey by the University of Arizonas Program in Integrative Medicine reports that their primary desire was to be
treated by a physician who was knowledgeable in both
conventional medicine and CAM.[271
In the ideal integrative clinic, the initial visit entails
an in-depth interview lasting from 60 to 90 minutes.
During this visit, the practitioner concentrates on understanding the patient as an individual, as well as delineating the medical history and determining desired
outcomes. After the initial interview and review of prior
records, a comprehensive treatment plan is formulated
and presented to the patient, not as a directive but as a
series of options to be chosen under the guidance of the
experienced practitioner. This approach provides the
greatest potential of adherence and success due to the
patients sense of participation and empowerment. Often
the treatment plan results in patient referral to other
specialized practitioners. For example, a dietician might
be suggested for nutritional counseling; a pharmacist for
medicatioddietary supplement counseling; a psychologist for hypnosis or guided imagery; or an osteopathic,
homeopathic, or TCM practitioner to address specific
issues. The patient is then followed either by return visits or by telephone to determine either success or need
for treatment plan modification.

C ~ A L L ~ N GT E INTEG
~
RATlVE MEDlClNE
Because the integrative model incorporates practices that
are often deemed quackery and unsafe by many conventional practitioners, there has been significant vocal
and written opposition to the growth of CAM, in general,
and integrative medicine, in particular.] One such avenue of opposition has been to block or strongly discourage
incorporation of CAM teachings into medical school curricula.O1Despite this resistance, 60% of medical schools
and 72% of pharmacy schools have incorporated CAM
into their curriculum.r28,291 One significant endeavor to

Table 1 Current members of the Consortium of Academic

Health Centers for Integrative Medicine

Albert EinsteinNeshiva University College of

Medicine, New York
Duke University School of Medicine, North Carolina
Georgetown University School of Medicine, Virginia
Harvard Medical School, Massachusetts
Jefferson Medical College, Pennsylvania
Stanford School of Medicine, California
University of Arizona College of Medicine, Arizona
University of California- San Francisco
School of Medicine, California
University of Maryland School of Medicine, Maryland
University of Massachusetts School of
Medicine, Massachusetts
University of Minnesota Medical School, Minnesota

close the gap between consumer demand and professional

response has been the formation of the Consortium of
Academic Health Centers for Integrative Medicine.[301
Their mission is to become a significant voice addressing
the importance of reevaluating and restructuring medical
education, and to have integrative medicine programs in
one-fifth of the United States medical schools within
the next few years. Table 1 lists the current members of
the consortium.
Another challenge to the growth of integrative medicine lies in the realm of reimbursement policies. Although third-party payers are increasing coverage of some
CAM modalities, this tends to be a slow and erratic pro~ e s s . [ ~Because
l]
CAM therapies tend to be less costly
than conventional interventions, reimbursement should
increase as research validates efficacy and cost effectiveness. If hypnosis decreases pain and eliminates the need
for lifelong use of addicting medications or if techniques
such as Feldenkrais prevent or postpone orthopedic surgery, the cost savings could be great for a healthcare system currently in economic crisis.
Difficulties have also arisen in relation to funding of
CAM research. This has been partially addressed by the
establishment within the NIH of the NCCAM and the
ODs. However, NCCAM and ODS grants tend to be
awarded to those following the conventional reductionistic
research model when investigating a CAM modality (e.g.,
studying a single acupuncture point rather than acupuncture or TCM as a whole). Although this approach may
add another tool to the conventional medicine arsenal, it
does not address the fundamental questions of whether a
different medical system (e.g., TCM) or a new medical
model (integrative medicine) is appropriate and effective.

Integrative Medicine

Research methodologies must be developed that allow for

studying systems as a whole (e.g., using systems theory or
multidimensional outcome measures) to determine whether component parts are truly synergistic.[321A small step
in the right direction has been the creation of four botanical centers by ODS~
These centers are charged with
studying the effects of marketed dietary supplements currently purchased and used by the public, rather than the
reductionistic search for a solitary active principle.
Another roadblock on the path to credibility is an apparent bias on the part of mainstream medical journals
when reviewing research or position papers on CAM or
integrative medicine. Journals may appear to be more
willing to publish negative results for CAM modalities
than those that indicate a positive outcome.[331Although
editors insist that the review process is objective, it may
be that the bar is set higher for CAM, and such bias has
been recognized by such authorities as the editors of the
New England Journal of Medicine.[341As research methodology in the CAM field improves and a biased editorial policy is corrected, the system of peer review may
be more fairly applied to all scholarly submissions.

Given the current state of healthcare in the United States,

most efforts by the political, academic, and corporate
entities have been in the direction of repair of the system
rather than creation of a new model. The results of these
labors have been equivocal at best. A growing number of
people planning the future of healthcare now envision the
need for a totally new system, one that retains the beneficial technologies of conventional medicine while
returning the focus of the profession toward health rather
than
The result would be a system of healthcare in which the public once again trusts and respects the
healthcare practitioner as an ally, rather than as part of
what often appears to be a mechanistic, profit-driven industry. Integrative medicine as a new medical model may
fill the need for a totally new system, such that in the
future the term integrative will no longer be needed,
and we will all simply practice good medicine.r301

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approach to medicine and to medical education. Integrative
Med. 1998, 1 (2), 67-73.

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2. Maizes, V.; Caspi, 0. The principles and challenges

of integrative medicine. West J. Med. 1999, 171 (3),
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3. Guerrera, M.P.; Ryan, A.H. Integrative medicine: An old
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PROFESSIONAL RESOURCES

nt

stracts (A

Carol Wolfe
American Society of Health-System Pharmacists,
Bethesda, Maryland, U.S.A.

INTRODUCTlO

HISTORY

International Pharmaceiitical Abstracts (IPA) is the

official abstracting and indexing service of the American
Society of Health-System Pharmacists. IPA is unique
in its international coverage of pharmacy and related
health journals.

The inaugural issue of IPA was published in January 1964

under the leadership of IPAs founding editor, Donald E.
Francke. The seminal concept for IPA was created in
1957 when Dr. Francke established a section called
Selected Pharmaceutical Abstracts in the Bulletin, the
forerunner of the American Journal of Health-System
Pharmacy. Dr. Franckes early objective for IPA was to
serve as an alerting service to keep the busy pharmacy
practitioner, professor, researcher, and student keenly
aware of a wide variety of information to permit him to do
a better professional job.
In late 1966, Dwight R. Tousignaut succeeded Donald
Francke as editor of IPA. IPAs production process was
computerized in 1970, and ZPAs first electronic licensing
arrangement was formalized in 1971 in an agreement to
supply magnetic tape to the National Library of Medicine
for use in its ToxLine database.
The International Pharmaceutical Abstracts (Coden:
IPMAAH; ISSN: 0020-8264) is published by the American Society of Health-System Pharmacists twice each
month, on the 1st and 15th. Its circulation is primarily
electronic. The print and electronic subscription rates
are available upon request. Internet access to IPA PharmSearch is available at $90 per 100 searches. The editorial and subscription offices are located at 7272
Wisconsin Avenue, Bethesda, Maryland 208 14, U.S.A.
(Telephone: 301-657-3000, extension 1241; Fax: 301664-8857; E-mail: ipa@ashp. org; Web site: http://www.
ashp.org; Managing Editor: Victoria Ferretti-Aceto).
The first edition of the IPA Thesaurus and Frequency List was published in 1981. Now in its eighth
edition, the Thesaurus provides a controlled vocabulary
designed to support robust searching of pharmaceutical literature.

An expert panel selects, abstracts, and indexes the most

pertinent articles from over 600 journals published
throughout the world. Translators with pharmacy expertise review the major pharmacy journals published in
languages other than English and prepare abstracts in
English. In addition, ZPA publishes abstracts of meetings
conducted by the American Society of Health-System
Pharmacists and the American Association of Colleges of
Pharmacy. Over 15,000 abstracts per year are added to the
IPA database covering the clinical and scientific literature
related to pharmacy, as well as legal aspects, professional
practice issues, and trends in education and research.
IPAs unique structure supports searching by drug class,
disease state, MeSH heading, generic or trade drug name,
and chemical registry number.
Examples of topic areas targeted for coverage are drug
evaluations, pharmacology, investigational drugs, toxicity, therapeutic advances, new technology, herbals, and
adverse drug reactions. Although a printed version of IPA
is available from ASHP, use is now primarily electronic.
Online versions are available by subscription through
several database vendors, including Silverplatter, Ovid,
Dialog, Cambridge Scientific Abstracts, STN International, DataStar, DIMDI, and EBSCO Publishing.
Individuals may also economically purchase online
search blocks by selecting IPA PharmSearch at
www.ashp.org.

Encyclopedia of Clinical Pharmacy

DOI: 10.1081E-ECP 120006388
Copyright 0 2003 by Marcel Dekker, Inc. All rights reserved.

487

PROFESSIONAL ORGANIZATIONS

Elizabeth Tracie Long

ISPOR-International Society for Pharmacoeconomics and
Outcomes Research, Lawrenceville, New Jersey, U.S.A.

The International Society for Pharmacoeconomics and

Outcomes Research (ISPOR) is a nonprofit, 501(c)(3)
member organization governed by an annually elected
board of directors, with administrative headquarters
located in the heart of central New Jerseys pharmaceutical corridor. (3100 Princeton Pike, Building 3, Suite D,
Lawrenceville, New Jersey 08648; Tel: 609-219-0773;
Fax: 609-219-0774. Its mission is to translate research
and outcomeshesults in pharmacoeconomics into practice to ensure fair and efficient distribution of healthcare resources.

The International Society for Pharmacoeconomics and

Outcomes Research (ISPOR), formerly the Association for Pharmacoeconomics and Outcomes Research
(APOR), was founded in 1995 by a group of 32 healthcare professionals and researchers with the goal of
developing research practice standards for assessing the
value of healthcare therapies to consumers, healthcare
systems, and societies. In 1997, APOR merged with the
International Society for Economic Evaluation of
Medicines to form ISPOR, the first and largest international pharmacoeconomics society. In 1998, ISPOR
launched Value in Health, the definitive, peer-reviewed
journal for this scientific discipline. In that same year,
two regional ISPOR chapters were established in Russia
and Poland, and collegiate chapters were organized
across the United States and Canada for students in the
field. The student chapters include the University of
Texas at Austin, University of Arizona, University of
Toronto, University of Louisiana at Monroe, University
of Michigan, University of Washington, University of
Southern California, and the University of Maryland.
488

With a steadily growing membership of 2000 representing 29 countries, ISPOR remains steadfast in its
mission to translate pharmacoeconomics and outcomes
research into practice to ensure that society allocates
scarce healthcare resources wisely, fairly, and efficiently.
The Society serves the public interest by:
Providing a forum that fosters the interchange of
scientific knowledge in pharmacoeconomics and patient health outcomes.
Facilitating and encouraging communications among
the research community, healthcare professionals,
governmental, educational groups, the media, and the
general public.
Educating public and private agencies on the usefulness of research in pharmacoeconomics and patient
outcomes assessment.
Acting as a resource in the formation of public policy
relevant to pharmacoeconomics, healthcare outcomes
assessment, and related issues of public concern.
Promoting this area of scientific research by providing
services and educational activities that advance it.
Representing the discipline before public and governmental bodies.
To implement these objectives, ISPOR has created
several steering committees and task forces to lead the
initiatives, formulate strategies, and promote good research practices. They are:
0
0
0
0
0

Health Science Steering Committee.

Prospective Studies.
Modeling Studies.
Retrospective Database Studies.
Outcomes Assessment Using Quality of Life Indicators.
Use of PharmacoeconomicDIealth Economic Information in Health Care Decision making.
Encyclopedia of Clinical Phamacy
DOI: 10.1081E-ECP 120006292
Copyright 0 2003 by Marcel Defier, Inc. All rights reserved.

489

International Society for ~ h a r ~ a c o ~ ~ ~ ) nand

n m~~uc ~s c o m
Research
e~

Medical Information Access.

Code of Ethics.
* Education Steering Committee.
e
Fellowship.
* Short Course Development and Quality Assurance.
Pharmacocconomics and Outcomes Rcsearch Curriculum Development, North America.
c
Pharmacoeconomics and Outcomes Research Curriculum Devclopmcnt, Europc.
0

Currently, TSPOR initiatives include developing standards of research practiccs to guide the activities of those
conducting pharmacoeconomics and outcomes research,
and devcloping educational programs to communicate
those research results to healthcare decision makers who
could greatly benefit from it.
ISPOR members are scientists, economists, and healthcare practitioners from 29 different countries and four
different work environments: academia, the pharmaceutical and biotechnology industry, research and consulting
organiations, and healthcare practice environments (hospitals, clinics, private practice, managed care, pharmacy
benefit management, clinicians, and govcrnmcnt). Thcir
educational backgrounds retlect degrces in statistics,
nursing, accounting, economics, business administration,
public hcalth, and other health sciences. A number possess doctoral degrees in medicine, philosophy, pharmacy,
public health, and jurisprudence.
Through thc ISPOR administrative staff, members are
provided with a variety of scrvices to support their research and processional growth, including:
*

www lspor org-the Society's web site which provides

key reocarch, educational, and public intormation on
thc dimpline, the organization, and its mcmbcr,
LEXICON-a
unique dictionary of pharmacocconomics and outcome\ research terminology.

Vulue in Health-the official pecr-reviewed research

journal of the Society published bimonthly.
* ISPOR NEWS-a bimonthly newsletter featuring the
latest research activities and employment opportunitics.
PRAP (Professional Recruitment Assistance Program)-provides a specialized job placement service
to members.
The Annual International Meeting (generally held in
May each year) and Annual European Conference
(generally held in November or December each year)promote the discipline of pharmacoeconomics and
outcomcs research through networking and education.
0
Student chapters, special interest groups, steering
committees, and task forces allow members to target
and affect issues of particular interest to them and to
thc discipline.
@

The current 1SPOR 2000-2001 Board of Directors is

as follows: President: Jon C. Clouse, M.Ph., M.S., Ingcnix
Pharmaceutical Services; President-Elect: Eva Lydick
Ph.D., SmithKline Rcccham; Past President: Bryan R.
Luce Ph.D., M.B.A, MEDTAP International; Directors:
A. Mark Fcndrick M.D., University of Michigan Mcdical
Center; Karen Rascati R.Ph., Ph.D., University of Texas;
Joan Rovira Ph.D., University of Barcelona and SOTKOS;
Kent H. Summers Ph.D., Eli Lilly & Company; Adrian
Towse M.S., Mphil, Office of Hcalth Economics (United
Kingdom); and Executive Director: Marilyn Dix Smith
R.Ph., Ph.D.

PROFESSIONAL ORGANIZATIONS

American Association of Colleges of Pharmacy,

Alexandria, Virginia, U.S.A.

INTRO
The Janus Commission was established by, 1995-96,
AACP President Mary-Anne Koda-Kimble to scan the
healthcare environment and to identify, analyze, and
predict those changes within the environment likely to
profoundly influence pharmacy practice, pharmaceutical
education, and research, and to alert the academy to both
threats and opportunities that such environmental changes
present. The Commission took its name from the Roman
god Janus, which had one head with two faces capable of
looking in opposite directions at the same time.

The Commission chose to define the environment as

encompassing the healthcare delivery system, health
professions education, the academic health center and
research enterprise, and the related social, economic, and
political forces which impact these three areas. It has did so
by recognizing that this did not constitute the entire environment which could be considered in such a discussion.
The Commission convened via face-to-face meetings
and conference calls throughout 1996 and 1997 and extensively discussed several issues. Throughout its deliberations, the Commission was drawn repeatedly to the
pervasive influence of a changing, more intensively integrated and managed healthcare system on both pharmaceutical education and pharmacy practice. This fundamental
change in healthcare was the primary influence in the
Commissions thinking and recommendations.

MIS
The Commission believes that a revised model for pharmaceutical education is needed to meet the challenges
presented by the changing healthcare system. In particuEncyclopedia of Clinical Pharmacy
DOI: 10.1081E-ECP 120006192
Copyright 0 2003 by Marcel Dekker, Inc. All rights reserved.

lar, schools and colleges of pharmacy must become true

activists in healthcare policy, services delivery, and
research in order to effectively achieve their missions in
professional education. Employing the analogy of the
pharmaceutical industry, the Commission suggests the
following fundamental areas of emphasis for schools
and colleges:
The need for enhanced research and development
activities related to the provision of, compensation for,
and outcomes of pharmaceutical care.
Sustained curricular reform efforts that ensure successful manufacturing of competent and caring
pharmaceutical care providers.
Aggressive marketing programs, working in collaboration with the profession of pharmacy, that
promote the delivery of pharmaceutical care and foster
enhanced practiceteducation partnerships.
Enhanced interaction with the product of professional education programs-the
pharmacist-to
ensure that graduates can and will continue to provide
effective clinical, humanistic, and economic outcomes
in the course of their professional careers.
Finally drawing upon the previous works of the Pew
Health Professions Commission and the AACP Commission to Implement Change in Pharmaceutical Education,
the Janus Commission believes that fundamental actions
must be taken immediately within the academy to ensure
the future success of our professional programs and
graduates within the evolving healthcare system. Among
these are:
Completion of the evolution of the values system
of pharmaceutical education toward producing graduates who are patient-centered providers of pharmaceutical care.
* Active involvement by administrators and faculty of
colleges and schools of pharmacy in healthcare sys491

J a m s Commission (AACP)

492

tem decision making, policy determinations, and research activities.

Creation by colleges and schools of action-oriented
business plans that result in effective partnerships with
practice organizations and healthcare delivery systems.

The Commission encourages a thorough and critical

reading of its report and looks forward to a very healthy,
lively, and productive dialogue within the Academy.

Robert H. Hunter
Merck & Company, West Point, Pennsylvania
Robert A. Kerr
University of Maryland, Baltimore, Maryland
Helene L. Lipton
University of California, San Francisco, California
John W. Muuger
University of Utah, Salt Lake City, Utah

Jan

ion

J . Lyle Bootinun (Chair)

University of Arizona, Tucson, Arizona

Victoria F. Koche
Creighton University, Omaha, Nebraska

PROFESSIONAL ORGANIZATIONS

Joi

sio

ealt
Kathryn T. Andrusko-Furphy
Atascadero, California, U.S.A.

The Joint Commission on Accreditation of Healthcare

Organizations (JCAHO) is a private, voluntary, not-forprofit organization that serves as a gatekeeper for health
care quality and safety. Currently, more than 19,000
health care organizations in the United States and many
other countries are JCAHO accredited."] Since its earliest
inceptions almost SO years ago, JCAHO has striven to
establish health care standards and performance measures. The mission of JCAHO is to continuously improve
the safety and quality of care provided to the public
through the provision of health care accreditation and
related services that support performance improvement in
health care organizations.

The organization takes its origins from a peer-to-peerbased practice starting first in the early 1900s with the
American College of Surgeons, which established minimum hospital standards. The majority of early hospitals
participating could not pass even these minimum standards. Ernest Codman, MD, is credited as the father of
JCAHO. He proposed the end-result system of hospital
standardization. Under this system, a hospital would track
every patient long enough to determine whether the treatment was effective. If not effective, a determination would
be made as to why not.
In 1951, the American College of Surgeons were
joined by the American College of Physicians, the American Hospital Association, the American Medical Association, and the Canadian Medical Association to create
JCAHO as it is known today. The Canadian Medical Association has since withdrawn from JCAHO;"] however,
they continue a process similiar to the current JCAHO.
The governing body is made up of 28 members with a
diverse background in health care, business, and public
policy. Members include nurses. physicians, consumers,
Encyclopedia of Clinical Pharmacy
DOI: 10.1081E-ECP 120006293
Copyright 0 2003 by Marcel Dekker, Inc. All rights reserved

medical directors, administrators, providers, employers,

labor representation, health plan leaders, quality experts,
ethicists, health insurance administrators, and educators.
Their role is to provide policy and leadership oversight.
Currently, JCAHO accredits the following types of
organizations:
General, psychiatric, children's, and rehabilitation
hospitals.
Health care networks, including health plans, integrated delivery networks, and preferred provider
organizations.
Home care, including infusion, home health, hospice, personal care and support, and home medical
equipment.
Nursing homes and long-term care, including longterm care pharmacies.
Assisted living.
Behavioral health, including mental health, chemical
dependence, mental retardation, and foster care.
Ambulatory care, including outpatient surgery centers,
rehabilitation centers, infusion centers, group practices, and specialty centers, such as birthing centers,
endoscopic centers, and pain centers.
Clinical laboratories.

ACCREDITATION STATUS
Even though the accreditation process is voluntary, much
emphasis is placed by health care organizations to successfully achieve accreditation status. Hospitals who receive federal funding from the Centers for Medicare and
Medicaid Services, in particular, must adhere to the rigorous preparation and survey process. Because 80% of
the approximate SO00 hospitals or health care systems
receive federal funding, the JCAHO accreditation process,
although voluntary, takes on a lot more meaning if the
organization wants to continue to receive federal funds.
The Social Security Amendment passed in 1965 granted
493

494

hospitals deemed status in the 1960s if they were JCAHO

accredited. Organizations who were JCAHO accredited
were deemed compliant with the Medicare Conditions of
Participation for hospitals. Consequently, today the majority of hospital systems must participate in the JCAHO
accreditation process and adhere to its standards.
The long-term care (LTC) accreditation process is
actually the second oldest JCAHO program and has been
accrediting LTCs since 1966."] More than 2800 organizations participate in this program. However, unlike
hospitals, it has not received deemed status to date. Consequently, many skilled nursing home facilities continue
to not opt for JCAHO accreditation to the same level as
hospitals. Instead, they adhere to state licensing requirements alone. In the late 1990s, a resurged interest in the
LTC accreditation process occurred precipitated by managed care's interest in JCAHO accreditation. Many managed care organizations were requiring JCAHO accreditation to service their patient population and LTC beds.
However, the advent of the Prospective Payment System
(PPS) in 1999, fueled by the balanced Budget Act of
1996, has more recently left a mixed signal as to the value
and cost of being JCAHO accredited.
The home care accreditation program"] is one of the
more diverse processes. The reasons for the 6400 organizations to participate in accreditation are actually four
separate and distinct submarkets: home infusion pharmaceuticals; home medical equipment; home health, personal care, and support; and hospice. Collectively, these
entities are often referred to as alternate site. That is,
alternate to hospitalization. First, the home infusion or
home intravenous (IV) segment. As an organized form of
health care delivery, home infusion has only been in use
since the early 1980s. Early patients requiring home infusion services were generally those with chronic disease
in which lifetime hospitalization was not an option (e.g.,
short gut syndrome requiring parenteral or enteral nutrition, hemophiliacs requiring factor VIII). The changes
in the Medicare reimbursement structure or diagnosisrelated groups (DRGs) in the mid-1980s had only an indirect impact on the growth in patients serviced in the
home care setting because Medicare does not pay for
prescription medications, including most IV medications
in the outpatient or ambulatory setting. Mainly, the
growth in home infusion occurred due to the financial
pressures of managed care influences to release patients
more quickly from the hospital when therapies were
considered safe, yet required prolonged use of IV medications. For example, the use of IV antibiotics for the
treatment of such conditions as osteomyelitis and other
soft-tissue infections, such as cellulitis or status postsurgical infections. The human immunodeficiency syn-

Joint Commission for the Accreditation of Health-Care Organizations

drome epidemic of the late 1980s and early 1990s also

fueled the growth in the home infusion industry. However, this industry's interest in the home care accreditation program that started in 1998 stemmed more from
competitive marketing reasons and financial reasons more
from the pressures of managed care and other third-party
payers instead of federal funding. About this time,
JCAHO changed its name from the Joint Commission
on Hospital Accreditation to the Joint Commission on
Healthcare Organizations, thus acknowledging the changing shape of health care delivery.
The home health agency or skilled visiting nurse component of home care also has diverse reasons to seek
JCAHO accreditation. JCAHO received deemed status in
1993 for its Medicare-certified organizations. However,
non-Medicare agencies also exist across the United States.
In fact, not all states require agency licensing. However,
the movement in the last decade has been for states to
require agencies to be licensed. More often, similar marketing and financial motives to attract third-party payers
have also fueled the motivation for non-Medicare home
health agencies to seek JCAHO accreditation. However,
the Balanced Budget Act of 1996 has had profound
effects on home health agencies and forced the closure
and consolidation of agencies as PPS took effect on
October 1, 2000.
The hospice segment of home care usually has a
federal funding component as well. JCAHO just received
deemed status in 1999."] Originally, JCAHO had a separate accreditation program for hospice; however, the
hospice standards have been folded into the home care
standards manual.
Of this diverse segment of health care, home medical
equipment (HME) is probably the most diverse group
within this segment. Participants range from HME dealers
with little to no clinical expertise providing ambulatory
aids such as wheelchairs, walkers, and intense clinical
services and equipment, such as clinical respiratory therapists providing oxygen, ventilators, and apnea monitors.
Unlike hospitals and home health care that receive federal
funds through Medicare part A benefits, HME receives
federal payment through Medicare part B benefits. As of
yet, deemed status or the requirement to be JCAHO
accredited has not been a motivating factor for seeking
accreditation in this market. However, there are some
reports that it may be required in the future. Marketing
and financial reasons from third-party payers and managed care predominantly have been the motivating force
to voluntarily seek JCAHO accreditation. In addition,
other healthcare organizations, such as hospitals and LTC
facilities that are JCAHO accredited, require their vendors
to be accredited. This exempts these HME organizations

Joint Commission for the Accreditation of Health-Care Organizations

from being included in the hospital, home health, or LTC

organization's accreditation process.
With the changes in health care delivery, ambulatory
care is also a growing segment of accreditation. Currently, more than 1000 centers are accredited. These include
ambulatory surgery centers, community health centers,
group medical practices, Native American health clinics,
and other specialty centers. In addition, they received
deemed status in 1996.'31

ACC R EDIT
When not motivated to participate for involuntary reasons
such as the withholding of federal funding, most health
care organizations find the JCAHO accreditation process
to be an investment into risk management. Organizations
agree to be measured against national standards set by
health care professionals. No longer is the accreditation
process a set of minimum standards. Once the standards
emphasis were structural in nature. Structural standards
assumed that care should be good because the opportunity
existed for such, such as the right physical plant or the
right number of staff. In 1987, the Agenda for Change
was launched. Its emphasis is based on actual organizational performance and processes performed; that is, is the
care provided actually safe and quality oriented? Organizations during the last 10 years have had to show that
the care provided is in fact efficacious, efficient, cost
effective, and safe. JCAHQ has almost gone full circle
with Dr. Codman's origin idea, except the current JCAHO
process continues to be standards based, not just outcomes
based. Organizations must show that access to care is
timely, staff is oriented and competent, and sentinel
events and complaints are incorporated into the organization's assessment processes.
However, JCAHQ is also striving for a more continuous and data-driven process. The precursor to their
ORYX Initiative or outcomes performance measurement
was the IMS system first launched in 19Wt4] In 1998,
hospitals and LTC facilities began to participate in the
collection of outcomes data via select clinical measures
and began to submit that data to JCAHO for analysis.
Home care has followed suit in the year 2000. However, as of this writing, JCAHO is looking to modify its

495

home care requirements for collecting outcomes data

for ORYX.
The goal of the JCAHO accreditation process is that
it will continue to be standards driven with an increased
emphasis on continuous data. In the last few years, the
JCAHO accreditation process-in particular, for hospitals-has been challenged. Payers continue to challenge
the value of the accreditation process cost versus quality. As health care organizations continue to evolve,
change, and consolidate, so must JCAHO evolve, change,
and consolidate.
In 1999, the Board of Commissions established an
Oversight Task Force for the Accreditation Process Improvement (API) Initiative. The purpose is to oversee the
continuous improvement in the accreditation process."]
The resulting changes are intended to enhance the evaluation of critical patient safety and patient care functions
and to achieve an accreditation process that remains consultative and focused on performance improvement. A
white paper was published outlining a future operational
model that will continue to build and expand on technology, performance data, presurvey self-assessments, a
fully automated interface with JCAHO, increased surveyor development, and a more continuous accreditation
process. Instead of a once every 3 years site visit, two
18-month site visits would occur that evaluate select
standards. In addition, since health care entities are so
diverse, there is a desire to create a model that is more
data driven, less predictable, and more customized to an
individual organization.

www.jcaho.org.
1999-2000 Comprehensive Accreditation Manual for
Home Care. Joint Commission on Accreditation of Healthcare Organizations. One Renaissance Boulevard Oakbrook
Terrace, Illinois 6018 1.
2000-2001 Comprehensive Accreditation Manual for
Ambulatory Care. Joint Commission on Accreditation of
Healthcare Organizations. One Renaissance Boulevard
Oakbrook Terrace, Illinois 6018 1.
ORYX: The Next Evolution in Accreditation. Joint Commission on Accreditation of Healthcare Organizations. One
Renaissance Boulevard Oakbrook Terrace, Illinois 6018 1.

PROF ESSlON AL ORGAN IZATlONS

VS

Robert M. Elenbaas
American College of Clinical Pharmacy,
Kansas City, Missouri, U.S.A.

pharmacy, state boards of pharmacy). The member organizations of JCPP are as follows:
Because of the diversity of practice locales and specialties
found within pharmacy, there is no one professional
association of which all pharmacists are members. The
existence of multiple professional associations, each with
its own unique focus, is an effective way to meet many of
the professional needs of a highly differentiated practitioner population. However, it is important that these
organizations have a means to collaborate effectively on
major professional, regulatory, and legislative issues that
confront pharmacy. The Joint Commission of Pharmacy
Practitioners (JCPP) fulfills this need.

The JCPP was established in 1977 and serves as a

discussion forum on matters of common interest and
concern to the profession. As a discussion forum, JCPP
facilitates effective representation of pharmacists on
professional, educational, legislative, and regulatory
issues. Although JCPP has no intrinsic authority to speak
on behalf of its member organizations, discussions within
the JCPP forum have identified many areas of agreement
and have allowed participating organizations to adopt
identical positions on a variety of professional issues. The
significance of this is found in the fact that, collectively,
the member organizations of JCPP represent virtually all
pharmacy practitioners in all practice environments.

Academy of Managed Care Pharmacy (AMCPJ

100 N. Pitt Street, Suite 400, Alexandria, Virginia
22314; Phone: (703) 683-8416; Fax: (703) 6838417; Judith A. Cahill, Executive Director.
American Association of Colleges of Pharmacy
(UCP)
1426 Prince Street, Alexandria, Virginia 223 14;
Phone: (703) 739-2330; Fax: (703) 836-8982;
Lucinda L. Maine, Executive Vice-president.
American College of Apothecaries (ACA)
2830 Summer Oaks Drive, Bartlett, Tennessee
38134; Phone: (901) 383-8119; Fax: (901) 3838882; D.C. Huffman, Jr., Executive Vice-president.
American College of Clinical Pharmacy (ACCP)
3101 Broadway, Suite 650, Kansas City, Missouri
64111; Phone: (816) 531-2177; Fax: (816) 5314990; Robert M. Elenbaas, Executive Director.
American Council on Pharmaceutical Education
(ACPE)
20 N. Clark St., Suite 2500, Chicago, Illinois 60602;
Phone: (312) 664-3575; Fax: (312) 664-4652; Peter
H. Vlasses, Executive Director.
American Pharmaceutical Association (APhA)
2215 Constitution Avenue NW,Washington, DC
20037; Phone: (202) 628-4410; Fax: (202) 4296300; John A. Gans, Executive Vice-president.

The membership of JCPP is not composed of individual

pharmacists. Instead, JCPPs membership is composed of
national pharmacy organizations who themselves represent either individual pharmacists or entities critical in
some way to the practice of pharmacy (e.g., schools of

496

American Society of Consultant Pharmacists (ASCP)

1321 Duke Street, Alexandria, Virginia 22314;
Phone: (703) 739-1300; Fax: (703) 739-1321; R.
Timothy Webster, Executive Director.

Encyclopedia of Clinical Pharmacy

DOI: 10.1081/E-ECP 120006294
Copyright 0 2003 by Marcel Dekker, Inc. All rights reserved.

American Society qf Health-System Pharmacists

(ASHP)
7272 Wisconsin Avenue, Bethesda, Maryland
20814; Phone: (301) 657-3000; Fax: (301) 6528278; Henri R. Manasse, Executive Vice-President.
National Association of Boards or Pharmacy (NAB?)
700 Busse Highway, Park Ridge, Illinois 60068;
Phone: (847) 698-6227; Fax: (847) 698-0124;
Carmen A. CatiLone. Executive Director.
National Community Phar?nucists Association (NCPA)
205 Daingerfield Road, Alexandria, Virginia 223 14;
Phone: (703) 683-8200; Fax: (703) 683-3619;
Bruce Roberts. Executive Vice-president.
National Council qf State Pharmacy Association
Executives (NCSPAE)
4041 Devlin Court, Tallahassee, Florida 32308;
Phone: (850) 906-0779; Fax: (850) 893-1845;
Steven E. Glass, Administrative Manager.

JCPP meets four times each year, and those organizations

whose membership is composed of individual pharmacy
practitioners chair and host thc meeting on a rotational
basis (Le., AMCP, ACA, ACCP, APhA, ASCP, ASHP,
and NCPA). Participants in the quarterly mectings include the chief elected officers and staff of the member organizations.
Onc or more major topics for in-depth discussion are
identified for each meeting. Thesc topics rcprescnt issues
confronting the profession at that point in time where
there is value in exchanging information or seeking
collaboration among the member organizations. These
discussions may result in a consensus position among all

eleven organizations, or allow those organizations who

share a common point of view to identify each other and
work collaboratively. Over the years, JCPP has facilitatcd collaboration among its member organizations on
issucs dealing with pharmacy education, practitioner
licensure, professional and technical manpowcr, federal
lcgislation or regulations, and programs developed by
pharmaceutical companies that dircctly impact on pharmacy practice.
One initiative that is now organized and guided by
JCPP is a series of strategic planning conferences for the
profession-originally
titled Pharmacy in the twentyfirst Century (P-2 1). Although the first P-21 conference
in 1984 was organizcd through other means, JCPP was
rcsponsible for the P-21 conferences held in 1989 that
focused on Opportunities and Rcsponsibilities in Pharmaceutical Care, and in 1994 that dealt with The
Changing Healthcarc System: lmplications for Pharmaceutical Care.z, In 1999, with the immincnt dawn
of the twenty-first century, the P-21 moniker was dropped,
and the conference was titled Re-engineering the
Medication Use S y ~ t c r n . ~ ~

Pharmacy in the 21st Century. Planning for un Uncertain

Future; Be-lold, C., Halperin, J.A., Rinkley, H L , Ashbaugh, R.A., Eds.; American Association of Colleges of
Pharmacy: Alexandria, Virginia, 1985.
2. Proceedings. Conference on pharmacy in the 21st century.
Am. J. Pharm. Educ. 1989, 53, 1S--7XS.
3. Proceedings. Pharmacy in the 21st century. Thc third
strategic planning confcrcncc for pharmacy practice. Am.
Pharin. 1995, 1-5 1, Suppl.
4. Proceedings. Re-enginecring the medication-use system:
An interdisciplinary conference. Am. J . Hosp. Pharm.
2000, 57, 537-601.
1.

PROFESSIONAL DEVELOPMENT

n
Diane B. Crutchfiel
Pharmacy Consulting Care, Knoxville, Tennessee, U.S.A.

INTRODUCTlON

HISTORY

The role of the clinical pharmacist in long-term care,

also called a consultant pharmacist, continues to expand
with the recognition of drug-related problems that affect the quality of life of seniors. In addition to the
potential adverse outcomes associated with medicationrelated problems, the cost of these problems is staggering. In fact, the total annual direct medical cost of
medication-related problems in nursing homes exceeds
$7 billion."'

The concept of consultant pharmacy was first born in the

early 1970s with the formation of the American Society of
Consultant Pharmacists (ASCP), which has since also
become known as America's Senior Care Pharmacists.
About the same time, the centers for Medicare and Medicaid Services (formerly the Health Care Financing Administration) recognized the importance of medication
management for the frail elderly in nursing homes, and in
1974, required that all medications for Medicare residents
of nursing homes be reviewed on a monthly basis. In
1987, the requirement was amended so that all Medicare
and Medicaid residents are required to have a monthly
medication review by a pharmacist. In addition to the
need for therapeutic drug monitoring, pharmacists recognized the need for unit dose packaging and specialized
delivery services for nursing home residents in an effort to
reduce medication errors and increase the efficiency of
the systems.[31
A pharmacy career in long-term care is typically associated with the provision of consultant pharmacy services to nursing home facilities. More recently, however,
the opportunities for pharmacists in this practice setting
have expanded far beyond the role of providing medications and medication reviews to only nursing homes.

Consultant pharmacists closely monitor each nursing

home resident's medication regimen, monitoring for potential drug or disease interactions, dosing irregularities
or side effects, and for medication use that may be considered inappropriate for the geriatric resident. This review is multifaceted and takes into account the information provided in the written medical record, as well
as input from the staff, resident, and family. Various
services are provided to the facility (Table 1). Inservice
education programs are provided to the nursing staff
and to family or resident meetings, if requested. Consultant pharmacists frequently participate on interdisciplinary care plan teams that focus on individual resident
needs, such as fall risk assessment, weight loss evaluations, or pain management programs. Through ongoing
monitoring of quality assurance programs, the consultant assists the facility in providing quality improvement for better resident care and in meeting state and
federal regulations.
The success of consultant pharmacists' drug regimen
reviews was reported in the Fleetwood study, which
demonstrated that the reviews improved therapeutic
outcomes by 43% and save as much as $3.6 billion
annually in costs associated with medication-related
problems.[21

498

Table 1 Types of consultant pharmacist services

Drug regimen review
Drug information
* Quality assurance programs
e
Inservice education programs
* Therapeutic drug monitoring
0
Patient counseling
e
Pain management
e
Interdisciplinary care planning
0
Pharmaceutical care planning
e
Pharmacokinetic dosing services
e
Drug research programs
e
e

Encyclopedia of Clinical Pharmacy

DOI: 10.1081E-ECP 120006262
Copyright 0 2003 by Marcel Dekker, Inc. All rights reserved.

Long-Term Care, Clinical Pharmacy Careers in

Table 2 Job settings for consultant pharmacists

e
e

e
e
4
4

e
e

e
e
e

e
e
e
e
e

Nursing facilities (skilledlintermediate care)

Assisted living facilitieshoard and care homes
Correctional institutions
Hospitals (subacuteltransitional care)
Home health agencies
Industry
Mental institutions
Alcohol or drug rehabilitation centers
Mental retardation facilities
Community health centers
Retail pharmacies
Health maintenance organizations
Hospice
Retirement communities
Adult day care
Physician offices
Ambulatory care centers

(From Ref. [l].)

Terms such as consultant pharmacist and senior care

pharmacist are used interchangeably to describe the type
of pharmacist, rather than focusing on the physical setting.
In addition to providing services for 1.8 million residents
in more than 16,000 nursing homes in the United States,
consultant pharmacists also provide medications and
medication reviews for jails and prisons, home health
agencies. and assisted living facilities, among others
(Table 2 ) .

TRAINING AND
CE RTIFIGATION REQUIREMENTS
The usual training for a pharmacist in long-term care, or
senior care, is a background or strong interest in providing
care for the elderly. Beyond the pharmacy degree, there
are now more than 800 certified geriatric pharmacists
(CGPs) practicing in all areas of the world. The certification for recognition as a geriatric pharmacist first became available in 1997, and is administered by the Commission for Certification in Geriatric Pharmacy (CCGP).
The CGP is not required for a career in long-term care
pharmacy but is an asset for someone seeking a position in
the field related to geriatric pharmacy. The CGP has
demonstrated knowledge in the specific clinical areas that
are required for the provision of consultant services to the
elderly. In addition to educational training, the pharmacist
must possess excellent verbal and written communication
skills specific to the needs and considerations of the
elderly. It is imperative to have the ability to work effec-

499

tively with physicians, nurses. and other healthcare

providers because the interdisciplinary approach is key
to providing positive patient outcomes by improving the
quality of life for residents in the variety of available longterm care settings. Postgraduate training programs, or
short-term clinical rotations, are available in a variety of
geriatric-related topics, including dementia, Alzheimers
disease, geropsychiatry, and Parkinsons disease, through
the ASCP Research and Education Foundation.

PROFESSIONAL OUTLOOK
As mentioned previously, careers are not limited to those
serving the elderly who reside in a nursing home. Some
states require consultant pharmacist services in assisted
living facilities. As the senior population continues to
grow, so does the need for pharmacists trained specifically in the area of geriatrics.
Within the job settings, consultant pharmacists may be
self-employed or work for a provider pharmacy. Provider
services typically include the operation and management
of the medication distribution system and consultant
services typically refer to the clinical services. Some
consultants provide only the consulting services and
others provide consulting services, in addition to dispensing the medications.
Innovation has been the key word in the evolution of
the practice of consultant practice in long-term care
settings. Thus. it will continue to be a key to the future
success of pharmacists willing to step out of the traditional pharmacy practice settings and provide much
needed services to the growing senior population.

REFERENCES
1. www.ascp.com. Senior Care Pharmacy Facts. accessed
February 24, 2002.
2. Bootman, J.L.; Harrison, D.L.; Cox, E. The healthcare cost

of drug-related morbidity and mortality in nursing facilities. Arch. Intern. Med. 1997, 157, 2089-2096.
3. Webster, R.T. A perspective on consultant pharmacys
future: Changing information into dollars. Consult Pharm.
1989, 4, 8-12.

BIBLIOGRAPHY
http://www.ascpfoundation,org/.

www.aacp.org/students.
http://www.ccgp.org/.

PROFESSIONAL DEVELOPMENT

i
arbara Zarowitz
Henry Ford Health System, Bingham Farms, Michigan, U.S.A.

When care is managed, health systems are accountable for

providing high-quality clinical care, while balancing the
economic factors, to deliver cost-efficient health outcomes."' The application of business practices to health
care requires accountability for financial and clinical
outcomes. Financial accountability is ensured by applying
fixed reimbursement rates to the delivery of care and
services. Reimbursement rates are set by the government
[Centers for Medicare and Medicaid Services (CMS)],
insurance companies, or health maintenance organizations
(HMOs). Fixed reimbursement rates require that the
delivery system or physician group provide care for their
assigned patients at a set rate or premium. If the cost of
managing assigned patients exceeds the reimbursement
rate, the delivery system loses money. The system or
group of physicians is at risk for, or capitated for, the
management of their assigned patients.
Accountability for clinical outcomes is negotiated by
managed care organizations with independent practice
associations and preferred provider organizations (PPOs)
for a discounted fee for service. Physician providers accept a discounted fee for services rendered and agree to
abide by certain quality and utilization requirements in
return for access to a defined membership group. Quality standards for medical care have been established by
the National Committee for Quality Assurance (NCQA),
whose mission it is to improve health care in the United
States by providing information about the quality of
care and service delivered by managed health care sysThe Health Plan Employer Data and Information
Set (HEDIS) measures focus on specific quality issues
defined by NCQA and provides employers with standardized performance measures to compare managed
care organizations. Representative NCQA/HEDIS measures include the use of appropriate medications in asthma, chlamydia screening in women, controlling high
blood pressure, beta-blocker treatment post myocardial
infarction. and antidepressant medication management.
Employers evaluate plans based on these medical quality
indicators, as well as effectiveness of care, use of serEncjclopedin of Clinical Pharmacy
DOI: 10.1081/E-ECP 120006259
Copyright 0 2003 by Marcel Dekker, Inc. All rights reserved.

vices, cost of care, informed health care choices, and

health plan stability.
Managed care applies to a wide range of settings including HMOs, PPOs, integrated delivery systems (IDSs),
physician hospital organizations (PHOs), and point-ofservice plans.

CAREER CHOICES AND SETTIN

Managed care has penetrated most geographic areas within the United States and essentially all health care settings.
As a result, career opportunities for clinical pharmacists
are vast and diverse. While previously pharmacists interested in managed care positions were limited to settings
such as pharmacy benefit management (PBM) companies
or insurance companies, career opportunities in managed
care have expanded and are available in hospitals, clinics,
and private practices in both urban and rural areas.
Traditional managed care pharmacy roles were those
that placed the pharmacist in the PBM or insurance company setting to provide administrative, formulary management, prescription claims management, and contracting services. With increasing managed care penetration,
IDSs, physician practices, PPOs, PHOs, and HMOs are
hiring pharmacists to provide clinical services involving
both quality of care and utilization management functions. Representative pharmacy opportunities in managed
care are outlined in Table 1.

Managed care needs qualified clinical and financial

pharmacy managers, grounded in solid business principles
and clinical pharmacy skills. The doctor of pharmacy
degree is strongly desired in pharmacists who graduated
prior to 1995, and mandatory for recent graduates. Depending on the position focus, advanced training in pharmacoeconomics or managed care as either a 1-year
residency or 2-year fellowship is recommended. Doctor
501

502

Managed Care, Clinical Pharmacy Careers in

Table 1 Clinical pharmacy careers in managed care

Role

Typical settingsa

Retail network manager

HMO
PBM

Claims manager

HMO
PBM

Account manager

HMO
PBM
Drug company
HMO
PBM
IDS
HMO IDS
PPO
PHO
PBM
Drug company
HMO
PBM
Employer
PPO
PHO IDS
HMO
HMO IDS
PBM

Quality initiatives manager

Clinical specialist

Datdpopulation manager

Group practice pharmacist

Formulary manager

Manager of
clinical initiatives

Utilizatiodcase manager
New business developer
Contracting

Call center pharmacist

Home care pharmacist

Outcomes researcher

Drug information specialist

Information technology/
database manager

HMO
PBM
IDS
Employer
IDS
HMO
HMO
PBM
PBM
HMO
IDS
PBM
IDS
HMO.com
IDS
HMO
IDS
HMO
PBM
IDS
PBM
IDS
HMO
PBM

Typical functions
Contracting with retail pharmacies
Audit and compliance functions
Pharmacy reimbursement
Processing prior authorizations
Developing criteria for
new drugs
Managing each business ventures
Tracking financial performance
Marketing new programs
Compliance programs for
NCQA/HEDIS
Coordinating data management
Drug expert functions for providers,
members, and formulary functions

Management and analysis

of data for quality and
cost-reduction initiatives
Managing the groups patient
population and pharmacy costs

Typical prerequisitesa
Pharmacy degree
Retail experience
Business background
Pharmacy degree
Managed care experience
MBA
Pharmacy degree
PharmD

PharmD Res

PharmD Res or Fel

Pharmacoeconomics
PharniD

Identifying new strategies to

manage drug entries, formulary
reviews, and process
Design and implement cost-reduction
and quality initiatives

PharmD

Manage high-risk populations

as part of a team
Identifies new client opportunities
and develops business plans
Contracts with drug companies,
pharmacy providers, and/or physicians
providers for services and drugs
Provide telepharmacy services
to patients and providers
Compliance programs
Prepare, deliver, administer, and monitor
intravenous and enteral nutrition or
drug products to patients in their homes
Measure the value of therapeutic
interventions on the quality of life

PharmD

Research and develop answers to

questions related to drugs and
drug policy
Integrate and manage database functions,
informatics, and technology

PharmD

MBA
Pharmacy degree
Pharmacy degree
MBA
Pharmacy degree

Pharmacy degree

Pharmacy degree
Fel
PhD or PharmD
Pharmacy degree
Res
Pharmacy degree

(Continued)

Managed Care, Clinical Pharmacy Careers in

503

Table 1 Clinical pharmacy careers in managed care (Continued )

Role

Typical settingsa

Typical functions

Outpatient pharmacist

IDS
HMO

Direct patient care

IDS
PHO
PPO

Counseling and dispensing medications

Reinforce compliance and disease
management programs
Conditioddisease-focused clinics

Typical prerequisitesa
Pharmacy degree
Res
PharmD Res
Board certification

aEmployer group, Employer; HMO, health maintenance organization; PPO, physician provider organization; PHO, physician hospital organization; IPA,
independent practice association; IDS, integrated delivery system; PBM, pharmacy benefit manager organization; Res, residency training; Fel, fellowship
training;.com, Internet commerce sites for medications

of pharmacy students interested in a managed care career

should pursue external rotations in progressive managed
care settings. Experience with claims and benefit management, formulary management, disease management,
quality certification, and large relational databases is very
important. Pharmacists interested in account management
may benefit from formal training in business administration and finance. Table 1 summarizes career opportunities
that may require advanced training as a prerequisite.
Desirable skills and knowledge are summarized in
Table 2. In addition to academic training, managed care
pharmacists are called to respond to a rapidly changing,
often unstable financial and clinical environment. Individual behavioral characteristics that are helpful in these
circumstances may include flexibility and ease of response
to change, open-mindedness, .pioneerism, and respect
for the sense of urgency surrounding health care business
evolution. Many managed care organizations are willing to
hire pharmacists with desirable behavioral and clinical

Table 2 Desirable skills, knowledge, and behaviors of clinical

pharmacists in managed care
Problem-solving skills
Exemplary oral and written communication skills
Knowledge of population management and
pharmacoeconomic principles
Facility with large relational databases and
information systems
Business and financial expertise
Comfort with the measurement science
Solid clinical skills, knowledge, and behaviors
A sense of urgency
Comfort in rapidly changing, unstable environments
Motivated by challenge
Teamwork
Interpersonal skills

characteristics, realizing that knowledge related specifically to managed care practice can be acquired. Large
organizations, whether managed care organizations,
HMOs, IDSs, or PBM firms, are often willing to provide
on-the-job training to advance pharmacists skills in managed care. However, prospective employers may preferentially select candidates with previous managed care
experience, thus underscoring the importance of selecting
elective rotations in managed care settings.

GE

Many opportunities exist for career growth in managed

care practice settings, just as they do in other practice
environments. New graduates can usually qualify for staff
pharmacist careers in benefit design, clinical, data analyst,
or case management positions. Advancement can follow
experience at entry-level positions, with or without advanced skills enhancement through external degrees or
training programs. Much of the management of pharmacy benefits, irrespective of the site of practice, is
science and can be learned didactically. However, a significant component of success in a managed care pharmacy career, like other pharmacy career paths, depends on
facility with the art of the application of managed care
skills, knowledge, and strategies-the so-called craft of
the managed care pharmacist. The development of craft
skills requires experience through application. which can
only be learned during practice. Entry-level pharmacists
may move on to clinical manager or team leader positions, or transition into higher business or administrative positions.
A parallel track is available within PBM companies
for pharmacists with retail pharmacy experience. Pharmacy network management and contracting have be-

504

come important mechanisms for managing costs and

enhancing revenue to health plans and PBMs. Retail
pharmacy experience and business skills are desirable
characteristics for pharmacists desiring advancement in
the more traditional roles of pharmacists within managed
care organizations.
Board certification and other postgraduate credentials
may be useful to individuals, depending on their practice
setting. However, in general, these credentials have not
attained widespread acceptance as prerequisites for advancement within managed care organizations. The paucity of qualified individuals to deliver exemplary pharmacotherapy services, while balancing business and
financial prerequisites has led to a limited candidate pool
for managed care pharmacy positions. Over time, as a
greater number of pharmacists enter and advance in managed care clinical pharmacy careers, board certification,
certificate programs, and association affiliations or recognition may become more important delineators of highquality pharmacists. In the interim, it is more important
that pharmacists gain experience in the field and determine
their compatibility with a career in managed care.
Managed care pharmacists are moving up the ranks
within their organizations. In a survey conducted among
200 managed care pharmacists in 1997, the five most
frequent job titles were director of pharmacy, regional director of pharmacy, pharmacy manager, vice president of
pharmacy, and director of pharmaceutical divi~ion.'~'
Many clinical pharmacists report directly to vice presidents or chief executive officers within their organizations.

IES OF CLINICAL ~ H A R M A C Y
PRACTICE IN MANAGE
Hospice
Hospice services are often offered as part of an IDS or
managed care organization. Typically, when patients and
their families determine that end-of-life measures are
indicated, they search for options to make the patient
maximally comfortable, with appropriate care, and at an
affordable cost. Hospice care can be offered as a purchased service or a covered benefit. In most cases, hospice care is capitated and must operate within a budget or
lose money.[41 Pharmacists practicing in hospice settings
may be called on to optimize rational pharmacotherapy
and help to discontinue medications deemed no longer
necessary for patient comfort. In this regard, the pharmacist and the rest of the patient's care team are managing care within a capitated limit.

Managed Care, Clinical Pharmacy Careers in

All-Inclusive Care for the

There are several PACE programs across the United States

that serve as day care and/or home care opportunities for
elderly patients, referred to as participants.['] PACE programs offer an alternative to nursing home placement,
enabling frail elderly people to remain independent in their
homes within the community. When elders enroll in a
PACE program, their care becomes the responsibility of
the program. PACE programs are funded through medicare and medicaid. The PACE program is responsible for
provision of both drug therapy and medical care. Pharmacists can serve an important role in optimizing and
simplifying drug therapy, at lowest cost. Given that many
of the participants are seniors with multiple concurrent
medications, careful individualization of dose is essential
to minimize adverse events.

Utilization Mana~ement
Clinical pharmacists have been redeployed in ambulatory
managed care settings to work with primary care providers
to enhance both the quality and cost effectiveness of care
delivered.[3361
They are highly integrated within the system
of care delivery. Population management strategies are
used to identify the high-cost or low-quality providers with
the greatest need for pharmacy care management. Provider
profiles are used to continuously provide feedback to physicians, identifying cost-reduction and quality improvement opportunities. Clinical pharmacists can work with
individual physicians or groups, such as a PPO or PHO, to
ensure that the highest quality of care is provided within
the capitation limits of the plan or group. Improvements in
quality are accomplished through the pharmacists'' role in
the development of clinical guidelines and pathways,
while helping physicians understand the patients' ' pharmacy benefits. Pharmacists may also work with individual
high-risk patients to streamline drug therapy, decrease
cost, and improve patient medication safety.

pecialt~Clinics
In managed care, it is often a small percentage of patients
(approximately 20%) who are responsible for the majority
of the cost (80%)-often referred to as the 80/20 rule. It
has been shown to be cost effective to manage these highrisk patients in specialty clinics or programs. Disease
management programs offer many patients with specific
conditions, enhanced management strategies to improve

Managed Care, Clinical Pharmacy Careers in

the likclihood that they will achieve desired therapeutic

outcomes as outpaticnts. Managed care organizations
typically offer diseasc management programs in diabetes,
asthma, depression, and other conditions in which the
quality of follow-up and intervention has been shown to
vastly improve patient outcomes, such as anticoagulation.
In addition, specialty clinics are an approach to improving
the management of patients with specific disorders, such
as asthma, hypertension, and dyslipidemia~.'~]
Pharmacists may provide individualized care or participate as
team members for case management or disease management of high-risk patients.

N
There are numerous opportunities for clinical pharmacists to contribute to high-quality patient care, business
results, and drug benefit administration in a wide variety
of managed carc settings. Pharmacists are no longer limited to a narrow range of managed care opportunities
within PBMs. Managcd care settings offer intensity and
challenge for clinical pharmacists with opportunity for
upward mobility and career growth.

505

Bhssenbach, H ; Penna, P Pharmdccutical Services in

Managed Care In The MunagPd Cure Hundhook, Kongstvedt, P., Ed.; Aspen: Gaithersburg, 1996; 367-387.
2. National Committee of Quality Assurance, www.ncqa.org
(accessed Aug. 2000).
3. Sardinha, C. Managed care pharmacists: Leading the way
for a new millennium. J. Man Care Pharin. 1997, 3 (4),
383-388.
4. Virnig, B.A.; Persily, N.A.; Morgan. R.O.: DcVito, C.A.
Do medicare HMOs and medicare FFS differ in thcir use
of the medicarc hospice benefit'! Hospice J. 1999, 14
(1). 1-12.
5 . Eng, C.; Pcdulla, J.: Eleazer, G.P.; McCann, R.: Fox, N.
Program of all-inclusive care for the elderly (PACE): An
innovative model of integrated geriatric care and financing. J. Am. Geriatr. Soc. 1997, 45 (2), 223-232.
6. Barreuther, A. Academic detailing to influence prescribing. J. Man Care Pharm. 1997. 3 (6); 631-638.
7 . Alsuwaidan: S . ; Malone, D.C.; Rillups, S.J.; Carter. B.L.
Characteristics of ambulatory care clini
in Veterans Affairs Medical Centers. IMPROVE investigators. Impact of managed pharmaceutical care on resource utilimtion and outcomcs in Veterans Affairs
Medical Centers. Am. J. Health-Syst. Pharm. 1998, 55
( l ) , 68 -72.
I.

PROFESSIONAL DEVELOPMENT

c
Beverly L. Black
American Society of Health-System Pharmacists,
Bethesda, Maryland, U.S.A.

tremendous demand for well-qualified clinical pharmacists in managed care settings.

Health system integration has been a dominant phenomenon since the early 1980s, and the trend is likely to continue. Understanding health system integration and its
impact on pharmacy practice is challenging for many reasons, one of which is the continued rapid pace of change."]
Responding to the challenges of system integration is
also complicated by the various types of organizations that
are characterized as integrated health systems. In broad
terms, an integrated health system is one that brings together hospital, medical, pharmaceutical, and other health
services into a single organization and thereby offers the
prospect of lower cost, an improved and more consistent
quality of care, and greater marketing power. Managed
care organizations (MCOs), such as health maintenance
organizations (HMOs). preferred provider organizations
(PPOs), and independent practice associations (IPAs), are
considered integrated health systems because they manage healthcare services for a defined population, even
though they may not be fully vertically integrated.[*]
Regardless of their size, structure, or service mix,
integrated health systems have the same goal: to deliver
high-quality care to a defined population at a competitive
cost. If desired patient outcomes and standards of fiscal
performance are to be achieved, pharmaceutical care must
be delivered efficiently and consistently, and drug products must be used appr~priately.'~]
This is where the
clinical pharmacist plays a crucial role.
The growth of managed care in the United States has
fostered new and innovative roles for pharmacists in this
area, such as consulting, disease management, wellness
program development, technology assessment, and outcomes research. The skills necessary for these roles
include communication and mediation, assertiveness, assimilation of drug information, evaluation of clinical and
economic data, and the ability to work in teams. Demonstrating and documenting the value of these roles will
be essential to the future of the profession of pharmacy.[41
As in many other areas of pharmacy, there is currently a

506

0PPORTUNIT1ES
Gore Strengths of Pharmacy
Managed care pharmacists have identified the following
core strengths that pharmacists should have to enable them
to thrive in a managed care setting. Pharmacists should:
e

e
e
e

e
8

Have an established reputation and competency as drug

therapy experts.
Have established skills in automation and computer
technology.
Have a demonstrated understanding of, and appreciation for, quantitative and qualitative information.
Be committed to helping patients.
Be accessible to patients.
Be focused on drugs and knowledge related to
medications.
Be experienced in adapting skills for surviving in a
changing healthcare environment.
Possess a wealth of online information and databases.
Possess a strong clinical knowledge base and training
that can support case management.
Be experienced in applying data to business
applications.
Have access to automated dispensing technologies,
which have increased pharmacy's capacity to take on
additional responsibilities.
Have good organizational skills.
Possess leadership skills and be passionate about
furthering the success of the profession.

Essential Skills
The changing marketplace and different patient needs are
creating innovative roles for pharmacists in integrated

Encyclopedia of Clinical Pharmacy

DOI: 10.1081E-ECP 120006395
Copyright G 2003 by Marcel Dekker, Inc. All rights reserved.

507

Managed Care Phannacy Practice

health systems. However, unique skpus are necessary

for effectiveness in managed care; some of these skills
will require additional training and education. Also, a
different attitude is essential; for example, pharmacists
must be willing to take risks and accept new responsibilities-oaes that may be unlike those of a traditional
position.[51
There are certain skills that clinical and dispensing
positions have in the managed care setting. These include drug information knowledge, communication and
mediation skills, assertiveness, and the abiIity to work
in teams.
Drug ~n~ormation
knowledge
The trends that are occumng in managed care are those
of disease state management, outcomes, welhess program emphasis, technology, and pharmacoeconomics.
The important role of the pharmacist with regard to drug
information is to assimilate and combine information
with other components for use in the decision-making
processes. These include not only patient-specific decisions, but also formulary decisions, for the entire managed population.
Pharmacists have the specific background to make the
appropriate recommendations for product selection; however, is no longer the products pharmacologic advantage
over other medications the only factor in selection. Pharmacoeconomics and population characteristics, as well as
many other factors, must be considered.[6
Other essential skills for pharmacists in managed care
include the following.
Communication and mediation skills
Understanding what other healthcare team members are
looking for and communicating effectively is vital. As
pharmacists increase their involvement in direct patient
care, interacting with patients will require the ability to
present information in terms that the patient will
understand. With respect to being a mediator, the goals
of cost containment must be clearly understood and
accepted by all parties in order for success to be achieved;
this responsibility often falls to the pharmacist.
Assertiveness
Healthcare and pharmacy are not exempt from market
pressures, and pharmacists must accept the fact that,
unless they assert their role and importance in the services
that they offer, they may not be needed.

Ability to work in teams

The pharmacist must understand role definitions, develop
empathy for other team members, and acquire the skills
necessary to surpass expectations.I Team relationships
are essentially balancing acts that can be upset easily if
someone does not understand the practice philosophy or
the role definitions within the team.
Innovative positions
Managed care systems offer innovative pharmacy practice
positions in such areas as pharmacoeconomics, disease
state management, outcomes research, wellness program
management, and technology assessment. For individuals
willing to expand their pharmacy practice aqd develop
new skills, these positions can offer unique opportunities
and growth.
Care coordinators and clinic coordinators
Some organizations have created interdisciplinary rounding teams for inpatient care. The responsibility for
coordinating the transition from hospital to ambulatory
care is delegated to these teams. For example, pharmacists
from the Hh.IOs home N service attend rounds within the
contract hospitals, focusing on monitoring drug therapy
with respect to quality and cost effectiveness and facilitating a smooth transition from hospital to home care.
Many MCOs are using pharmacists to influence
physician prescribing and to conduct clinics promoting
appropriate use of pharmaceuticals. In addition, these
pharmacists participate in direct patient care activities
that relate to drug therapy, such as ordering and monitoring laboratory tests and providing effective patient
follow-up to ensure patient satisfaction and high-quality
care. Many of the pharmacist-coordinated clinics providing this patient care have been shown to improve patient outcomes and satisfaction and to support the
efficient provision of services from other members of
the healthcare team.@
Disease management and the patient
Disease management has been defined as quantifying,
tracking, and controlling the unique set of cost drivers in
any disease and the interactions of these drivers over the
course of the disease across all elements of the healthcare
~ystem.~lStudying the distribution and effects of medications in populations (pharmacoepidemiology),as well
as the costs and comparisons of alternative courses of

508

therapy (pharmacoeconomics), helps determine where

disease management can change practice the most.[lol
These conditions are generally the most common, expensive, and treatable (e.g., asthma, diabetes, peptic ulcer
disease, depression, cardiovascular disease) and provide
the greatest opportunity for economic savings when disease management programs focus on them."']
Disease management requires that pharmacists add a
number of skills to their professional role. These skills
include managing information systems to collect and
organize data, total quality management to improve processes, teamwork with patients and other professionals,
budgeting to obtain compensation, teaching clinical care
and appropriate drug use, and the ability to help move
pharmacy from compartmentalized care to integrated
care.[121Most models of disease management use the
pharmacist in a clinical role that goes beyond dispensing. Pharmacists are ideally qualified to participate in
disease management because of their knowledge of
drug therapy, communication, computer applications,
and marketing, as well as sales, finance, and basic
wellness issues. Pharmacists have a great opportunity in
these situations, given their ability to communicate
complex concepts in easily understood terms to help
employee groups take advantage of disease management option^."^]
In the future, as healthcare systems make the transition
from stage 1 (primarily fee for service) to stage 4 (primarily capitation), opportunities for disease management
will i n ~ r e a s e . " ~For
] many MCOs, shifting from formulary management to disease management will be a
means of improving the overall quality of care, reducing
costs, and expanding patient involvement in care.[151Decisions will not be based on individual components of
care, such as the cost of drugs or other treatments; rather,
a disease will be viewed in its entirety. As customized
cost-management techniques are applied to each disease
and patient, the pharmacist will assume a greater role in,
and responsibility for, patient outcomes."61

Managing health
Wellness programs have been described as the community outreach component of disease management. These
programs can link with disease management programs to
provide follow-up support.
Pharmacists are ideally positioned to play a major
role in wellness programs. Combining their outstanding
clinical skills acquired during formal education, internships, externships, and work experiences with significant
transferable skills, especially communication and interpersonal skills, makes pharmacists ideal candidates for

Managed Care Pharmacy Practice

counseling patients and producing the outcome of better

overall healthcare at lower costs. Application of principles
of disease prevention and management in individual or
group counseling sessions can help patients learn how to
care for themselves properly, thus reducing healthcare
costs and improving their quality of life."']
In the future, wellness programs will most likely be
a joint effort among payers, employers, patients, and
providers. In these programs, pharmacists could serve
as coordinators to ensure appropriate utilization of resources, effective communication, and optimal patient
outcomes."']

Evaluating clinical and economic data

The focus on disease state management and outcomes will
require that data on a patient's drug therapy be accessible
to both hospital and ambulatory care providers. The
pharmacist can play an integral role in the coordination
and dissemination of these data. For example, institutional
pharmacists will need to establish communication links
with pharmacy providers in other settings to ensure optimal and seamless care."']
Pharmacists can provide a valuable service in evaluating the data resulting from treatments and helping
patients make the most of their prescribed therapies.[201A
pharmacist could help select the appropriate formulary
drug within a drug class and then teach the patient how to
take the medication correctly.
Pharmacists also have a role as pharmacoeconomic
analysts in comparing medications. Sometimes the investment in a more expensive medication reduces other
costs to the HMO, but the data must be collected and
tracked for these assumptions to be proved. To perform
these analyses successfully, the pharmacist must be able
to evaluate and interpret statistics and research articles.
A sound understanding of pharmacoeconomic principles
is also essential.
As more information about a given treatment is received, the pharmacist must always be prepared to perform the analysis again and incorporate the new information. Depending on new research or changes in the
HMO-covered population and its needs, the pharmacoeconomic evaluation may lead to different results at a
later date.
Because of the financial pressures to reduce healthcare costs without compromising quality, the pharmacist
must have the ability to apply basic quantitative skills to
evaluate options and then to blend those results with
qualitative information to make decisions and recommendations.[211 Pharmacists will have to work directly
with prescribers, helping them interpret and use phar-

Managed Care Pharmacy Practice

macy claims data to achieve the best patient outcomes.

Having a basic understanding of business and knowing
when to seek additional information are increasingly
necessary to operate successfully within the managed
care environment.

Measuring outcomes
Measuring outcomes shifts the emphasis from products to
patient results, which could eliminate the need for formularies.[221simply put, outcomes measurements evaluate
systems and decide what works and what does not.
Healthcare providers are increasingly relying on pharmacists to perform outcomes research and quality-of-life
studies. Pharmacists can apply basic quantitative skills
in evaluating options and combine the results with qualitative information to make decisions and recommendations. For disease state management programs, measuring outcomes can be the key to success.[231
As health delivery systems move toward total managed
care, the need for outcomes studies will increase.i241
Issues to be addressed by outcomes research will include
clinical efficacy of interventions, health-related quality of
life, patient satisfaction. employee productivity, and resource utilization. Pharmacists can either participate in or
direct outcomes research. Outcomes studies may also be
used to support a pharmacy position for interventions.
Outcomes research must always be patient focused and
useful for improving patient care. Many pharmacists
already have the data to do their own outcomes research.
Questions about appropriate prescribing and compliance
can be answered by using pharmacy claims data. That
information could be a tool in providing positive feedback
to the patient, as well as to the prescriber.

L PRACTICES IN
M A N A G ~ DCARE
The American Society of Health-System Pharmacists
(ASHP) and the Academy of Managed Care Pharmacists
developed the Accreditation Standard and Learning
Objectives for Residency Training in Managed Care
Pharmacy Practice in 1997. This standard outlines specific requirements and principles that managed care
pharmacies should have in place for training residents.
The relevant practice areas include direct patient care,
drug information, population-based pharmaceutical care,
business administration and management activities, and
practice management. Regular accreditation surveys and
visits ensure that each site maintains the practice stan-

509

dards. The Managed Care Pharmacy Practice Standard

can be found on the ASHP web site.[251
In addition to the Accreditation Standard and Learning
Objectivesfor Residency Training in Managed Care Pharmacy Practice, ASHP has published the following standards and guidelines, which provide guidance on model
clinical practices to managed care pharmacies. (Note: The
citations provided are from the American Journal of
Health-System Pharmacy, but each of these standards or
guidelines can also be located on ASHPs web site.[361)
ASHP Guidelines on Pharmaceutical Services for Ambulatory Patients. [261
ASHP Guidelines: Minimum Standard for Pharmacies
~271
in Institutions.
ASHP Guidelines on a Standardized Method for Phar[2Sl
maceutical Care.
ASHP Guidelines for Obtaining Authorization for Documenting Pharmaceutical Care in Patient Medical
Records.[291
ASHP Statement on the Pharmacists Responsibility
for Distribution and Control of Drug Products.[301
ASHP Statement on the Pharmacists Role with Respect to Drug Delivery Systems and Administration
~311
Devices.
ASHP Technical Assistance Bulletin on Drug For~321
mularies.
ASHP Technical Assistance Bulletin on the Evaluation
1331
of Drugs f o r Formularies.
ASHP Guidelines on Medication-Use Evaluation.[341
ASHP Guidelines on Adverse Drug Reaction Monitor[351
ing and Reporting.
Other organizations that provide guidance on model
clinical practices are those that measure pharmacy quality
and utilization in the managed care area. The primary
organizations are as follows:
The Joint Commission on Accreditation of Healthcare
Organizations (JCAH0)-JCAHO began providing accreditation services by focusing on hospitals; more
recently, its services have been expanded to provide
accreditation services for a wide continuum of healthcare
providers. In fact, JCAHO shifted its accreditation focus
toward a continuous quality improvement (CQI) process
and incorporated outcomes measures into the standards.
Information on JCAHO and its standards can be found at
www.jcaho.org.
The National Committee for Quality Assurance
(NCQA)-NCQA was founded in 1979, in an effort to
establish a comprehensive quality measurement process

Managed Care Pharmacy Practice

510

for MCOs. The focus of the NCQA accreditation process

is the effective implementation of a CQI process into the
medical services provided by the managed care organization. Information on NCQA and its standards can be
found at www.ncqa.org.
The Health Plan Employer Data and Information Set
(HEDIS)-The
HEDIS reporting system is a series of
specific performance measures designed to provide
healthcare consumers with the information they need to
reliably compare MCOs. HEDIS measures are self-reported by participating MCOs on a quarterly basis. Information on HEDIS, which is a joint project with NCQA,
can be found at www.ncqa.or~pages/progr~s~edis.

~ e f @ r e n ~toe
Publishe~

setting. Some of the more prominent organizations

include the following:
The American Society of Health-System Pharmacists
Center on Managed Care Pharmacy (www.ashp.org).
The American Association of Health Plans (www.aahp.
or&.
The American Medical Informatics Association
(www.amia.org).
The American Telemedicine Association (www.
atmeda.org).
The Academy of Managed Care Pharmacy (www.
amcp.org).
The National Business Coalition on Hedth (www.
nbchorg).
SCRIPT (http://scriptproject.org).

References to published materials documenting the benefit of pharmacists in managed care settings include the
following:
Mistry SK. Helping primary care providers with
appropriate, cost-effective prescribing. Am J HealthSyst P ham . 2000; 57:1575.
Knapp KK, Blalock SJ, OMalIey CH. ASHP survey
of ambulatory responsibilities of pharmacists in managed care and integrated health systems-1999. Am J
Health-Syst Phaniz. 1999; 56243 1-43.
Carroll NV. Formularies and therapeutic interchange:
healthcare setting makes a difference. Am J HealthSyst P ham . 1999; 56467-72.
Knowlton CH. Pharmaceutical care in 2000: engaging
in a moral covenant in turbulent times. Am S HealthSyst P ham . 1998; 55:1477-82.
Kay B, Crowling GH, Kershaw VI et al. Perspectives
on pharmacys role in managed care. Am J Health-Syst
P ham . 1998; 55:1482-8.
Reeder CE, Kozma CM, OMalley CH. ASHP survey
of ambulatory care responsibilities of pharmacists in
integrated healthcare systems-1997. Am J HealthSyst P ham . 1998; 55:35-43.
Hawkins PR. Pharmacist as health education coordinator. Am J Health-Syst Pharm. 1997; 54:1497-9.
Hepler CD. Where is the evidence for formulary effectiveness? [Letter] Am J Health-Syst P ham . 1997;
54:95.
Additional citations validating the benefits of clinical
pharmacists participation in managed care are listed
in the Bibliography.

Professional ~etworking~ ~ p o ~ u n i t i e s
There are many professional networking opportunities for
clinical pharmacists who practice in the managed care

1. Knapp, K.K.; Blalock, S.J.; OMalley, C.H. Survey of

Managed Care and Ambulatory Care Pharmacy Practice
in Integrated Health Systems, 1999; ASHP: Bethesda, MD,
1999; 5.
2. Knapp, K.K.; Blalock, S.J.; OMalley, C.H. Survey of
Managed Care and Ambulatory Care Pharmacy Practice
in Integrated Health Systems, 1999; ASHP. Bethesda, MD.
1999; 5.
3. Survey of Managed Care and Ambulatory Care Pharmacy
Practice in Integrated Health Systems, 1999; ASHP:
Bethesda, MD, 1999; 5.
4. ASHP Center for Managed Care. Innovative Roles for Managed Care Pharmacists; ASHP: Bethesda, MD, 1998; 13.
5. Knapp, K.K.; Blalock, S.J.; QMalley, C.H. Survey of
Managed Care and Ambulatory Care Pharmacy Practice
in Integrated Health Systems, 1999; ASHP: Bethesda. MD,
1999; 3.
6. Knapp, K.K.; BIalock, S.J.; OMalley, C.H. Survey of
Managed Care and Ambulatory Care Pharmacy Practice
in Integrated Health Systems, 1999; ASHP Bethesda, MD,
1999; 4.
7. Knapp, K.K.; Blalock, S.J.; QMalley, C.H. Survey ofManaged Care and Ambulatory Care Phanmacy Practice in
Integrated Health Systems, 1999; ASHP: Bethesda, MD,
1999; 4.
8. Knapp, K.K.; Blalock, S.J.; 0Malley, C.H. Survey of
Managed Care and Ambulatory Care Pharmacy Practice in
Integrated Health Systems, 1999; ASHP: Bethesda, MD,
1999; 6.
9. Toscani, M.R. Introduction to Disease Management. In
Paper Presented at ASHP Midyear Clinical Meeting. hew
Orleans, LA,1996, Dec. 10.
10. Larson, L.N.; Bjornson, D.C. Interface between pharmacoepidemiology and pharmacoeconomics in managed care
pharmacy. J. Manage. Care Pharm. 1996,Z (3), 282-289,
May/Jun.

Managed Care Pharmacy Practice

511

1 1 . Marcille, J. Is there a place for pharmacists in the new

world of disease management? J. Manage. Care Pharm.
1996, 3 (I), 16-21. Jan./Feb.
12. Campbell, W.H.; Newsome, LA.; Ito, S.M.
The
Evolution of Managed Care and Practice Settings. In A
Phannacist s Guide to Principles and Practices of Managed Care Pharmacy; Ito, S.M., Blackbum, S. Eds.;
Foundation for Managed Care Pharmacy: Alexandria,
Virginia, 1995; Vol. 5. 13.
13. Innovative Roles for Managed Care Pharmacists; 7-8.
14. Toscani; 7.
15. Rosenburg, G.B. Opportunities for alliances between
industry and pharmacy. Am. J. Hosp. Pharm. 1994, 51,
3061-3065.
16. Marcille, J. Is there a place for pharmacists in the new
world of disease management? J. Manage. Care Pharm.
1996, 3 (I), 20, Jan./Feb.
17. Boysen, H. 1996, Personal communication, Oct.
18. ASHP Center for Managed Care. Innovative Roles for Managed Care Pharmacists; ASHP: Bethesda, MD, 1998; 8.
19. Bond, W.E. Direct contracting: The next purchaser strategy.
J. Manage. Care Pharm. 1996, 2 (I), 11 16; Jan./Feb.
20. Kostoff, L. 1996, Personal communication, Nov.
21. Boysen, L. 1996, Personal communication, Oct.
22. Marcille, J. Is there a place for pharmacists in the new
world of disease management? J. Manage. Care Phann.
1996, 3 (I), 18. Jan./Feb.
23. Buchner, D. Role and Importance of Outcomes Measurement in Maximizing the Success of Disease Management
Initiatives. In Abstract Presented at ASHP Midyear Clinical Meeting, New Orleans, LA, 1996; Dec. 11.
24. Gross, T. Considerations in Developing and Selecting
Disease Management and Outcomes Programs in Managed Care. In Paper Presented at ASHP Midyear Clinical
Meeting, New Orleans, LA, 1996; Dec. 10.
25. ~ . a s h p . o r g - p u b l ~ c - ~ - M C P H S ~ . h t ~ .
26. American Society of Hospital Pharmacists. ASHP guidelines on pharmaceutical services for ambulatory patients.
Am. J. HOSP.Pharm. 1991,48, 311-315.
27. American Society of Hospital Pharmacists. ASHP guidelines: Minimum standard for pharmacies in institutions.
Am. J. HOSP.Pharm. 1985, 42, 372-375.
28. American Society of Health-System Pharmacists. ASHP
guidelines on a standardized method for pharmaceutical
care. Am. J. Heath-Syst. Pharm. 1996, 53, 1713-1716.
29. American Society of Hospital Pharmacists. ASHP guidelines for obtaining authorization for documenting pharmaceutical care in patient medical records. Am. J. Hosp.
Pharm. 1989,46, 338-339.
30. American Society of Hospital Pharmacists. ASHP Statement on the Pharmacists Responsibility for Distribution
and Control of Drug Products. In Practice Standards of
ASHP 1996-97; Deffenbaugh, J.H., Ed.; American
Society of Health System Pharmacists: Bethesda, Maryland, 1996.
31. American Society of Hospital Pharmacists. ASHP statement on the pharmacists role with respect to drug delivery
systems and administration devices. Am. J. Hosp. Pharm.
1989,46, 2342-2343.
~

32. American Society of Hospital Pharmacists. ASHP technical assistance bulletin on drug formularies. Am. J. Hosp.
P h m . 1991,48, 791-793.
33. American Society of Hospitd Pharmacists. ASHP technical assistance bulletin on evaluation of drugs for
formularies. Am. J. Hosp. Pharm. 1988, 45. 386-387.
34. American Society of Health-System Pharmacists. ASHP
guidelines on medication-use evaluation. Am. J. HeathSyst. Pharm. 1996, 53. 1953-1955.
35. American Society of Hospital Pharmacists. ASHP guidelines on adverse drug reaction monitoring and reporting.
Am. J. HOSP.P h m . 1995, 52, 417-419.
36. www.ashp.org.

Following are some selected references to published

materials validating the benefits of pharmacists participation in managed care:
Butler, C.D. Practical approaches to meaningful outcomes
analysis. ASHP Home Care Meet. 1995, 2, HC-24, Aug.
Goss, T.F. Overview of outcomes studies conducted in managed
care organizations. ASHP Midyear Clin. Meet. 1996, 31, PI58, Dec.
Grasela, T.H. Pharmacoepidemiology: Scientific basis for outcomes research. Ann. Pharmacother. 1996,30,188- 190, Feb.
Hedbfom, E. Process of identifying medication-relatedoutcomes.
ASHP Annu. Meet. 1996, 53, PI-85, Jun.
Horn. S.D. Clinical practice improvement model and how it is
used to examine the availability of pharmaceuticals and the
utilization of ambulatory healthcare services in HMOs.
PharmacoEconomics 1996. 10 (Suppl. 2), 50-55.
Horn, S.D.; Sharkey, P.D.; Phillips, H.C. Formulary limitations and the elderly: Results from the managed care
outcomes project. Am. J. Managed Care 1998, 4, 11051113, Aug.
Horn, S.D.; Sharkey, P.D.; Levy, R. Managed care pharmacoeconomic research model based on the managed care
outcomes project. J. Pharm. Pract. 1995, 8, 172-177. Aug.
Hughes, T. Research in managed care: Outcomes research in
disease prevention and management. J. Managed Care
Pharm. 1996, 2. 212; 214; 216; 221-222, May-June.
Leon, J.; Neumann, P.J. Cost of Alzheimers disease in managed
care: A cross-sectional study. Am. J. Managed Care 1999,5,
867-877, JUl.
Lindgen, D.L. Issues for managed care pharmacy. Am. Pharm.
1995, NS35, 51-58, Aug.
Parker, D.A. Advancing outcomes research in managed care
pharmacy. J. Managed Care Pharm. 1998,4,257-258,261271; 266-267, May-June.
Robison, R.N. Prioritizing managed care organization needs for
outcomes studies and identifying disease Management programs and outcomes studies worth implementing: Managed
care medical directors perspective. ASHP Midyear Clin.
Meet. 1996, 31, PI-59, Dec.
Wernsing, D. Health outcomes and managed care. Drug Benefit
Trends 1996, 8 (Suppl. C), 29-35, Mar.

PHARMACY PRACTICE ISSUES

[ear

rams

Albert I . Wertheimer
Stephen H. Paul
Temple University, Philadelphia, Pennsylvania, U.S.A.

INTRODUCTION
There are two major government supported healthcare
programs in the United States today. They are completely
different in structure, purpose, and financing. One is
Medicaid, which is operated by the state governments with
financial support from the federal government. This support varies but is generally in the range of 53-80% of total
expenditures, depending upon the state's per capita
income. Medicaid is Title 19 of the Social Security laws
and was enacted in 1965. It is intended for medically indigent persons. Such low-income persons must pass a
means test of income and wealth maximum criteria. In
1998, about 40.6 million persons received benefits at an
expense of $142 billion. Medicaid can be seen as a welfare
program to replace the very different programs operated
by states and counties before 1965, which had different
eligibility criteria, benefit structures, and waitinglresidency requirements impacting persons who moved residences.
In essence, it standardized welfare programs."'
Medicare, on the other hand, was established also in
1965 to provide assistance for medical expenses for the
aged and disabled. It is not a welfare program, but rather
an insurance program, as beneficiaries have their premiums deducted from their monthly social security
checks. All persons 65 years of age and above are eligible for hospital insurance (called Part A). Part B is a
supplemental health insurance plan covering physician's
and surgeon's fees, laboratory work, and other outpatient
services. In 2000, 39.33 million persons were enrolled in
Part A and 37.4 million of these were enrolled in Part B.
This is an insurance program funded by enrollee payments of about S50.00 per month. Part A is funded by a
tax on incomes of all persons of 7.65%.12] Medicare is
operated directly by the federal government through the
Social Security Administration.
The role of drugs and pharmaceutical services could not
be any different. In Medicaid, every state program has an
outpatient drug benefit that covers virtually all prescription
and OTC drugs available in the United States. There are
some differences among the states, which will be discussed
512

later. However, there has never been an outpatient drug

benefit in Medicare. It has been discussed, and legislative
initiatives have been planned, but it has not been brought to
fruition in the 35-year history of the program. Medicare
covers drugs used while a patient is hospitalized. Estimates
of the likely cost of such an outpatient program are
massive, and there is controversy as to the need.

MEDICARE: DESCRIPTION AND

CONTACT POINTS
Medicare is the health insurance program f o r people 65
years of age or older, certain younger individuals with
disabilities, and citizens with End-Stage Renal Disease
(permanent kidney failure with dialysis or a transplant.
sometimes called ESRDJ. This program is administered by
the Department of Health and Human Services through
the Health Care Financing Administration (HCFA) of the
United States federal government.

* Contact with HCFA can be accomplished over the Internet at: http://www.hcfa.gov or http:l/www.medicare.
gov.
* Via the telephone by calling: 1-800-Medicare (1-800633-4227).
* Or by mailing the Medicare agency at: U.S. Department of Health and Human Services; Health Care
Financing Administration; 7500 Security Boulevard;
Baltimore, Maryland 21244- 1850.

History
The quest for universal healthcare in the United States
started during the depths of the great depression in the
1930s. President Franklin D. Roosevelt wanted it, however, American medicine vehemently opposed it. From
that point, the protagonists and antagonists have been
fighting the battle. The goal appeared to be in reach numerous times during the last 70 years; however, an inciEncyclopedia of Clinical Pharmacy
DOI: 10.1081E-ECP 120006184
Copyright '02003 by Marcel Dekker, Inc. All rights reserved.

Medicaid and Medicare P

a Programs
c e ~

513

dent always came along to derail comprehensive reform.

In 1965, the Great Society under President Lyndon B.
Johnson moved forward with legislation providing a level
of care for the elderly (Medicare). Medicaid was also enacted at the same time to cover low-income aged, blind,
and disabled individuals, and parents and their dependent
children on welfare. Piecemeal health coverage for select
populations was continuing, and comprehensive reform
was thwarted. These two federally initiated health proposals did not include mandatory ambulatory drug coverage. In 1988, the Medicare Catastrophic Act was signed
into law by President Ronald W. Reagan and promptly
vetoed by President George H. W. Bush before it could be
implemented. This legislation would have provided a prescription drug benefit and a cap on patient liability. The
law was rescinded, because high-income elderly felt they
would pay more in premiums than they would receive in
benefits.Dl
The passage of the Omnibus Budget Reconciliation
Act (OBRA) of 1990 provided poor seniors who qualified
for Medicare and Medicaid a level of mandatory patient
care provided by pharmacists in addition to
prescription coverage.
The 1990s witnessed the creation of optional nonfederal prescription benefits for Medicare beneficiaries
enrolled in Health Maintenance Organizations (
and in 1997, Medicare+Choice was established by Resident William J. Clinton which created numerous choices
for recipients. The start of this millennium has witnessed
the commitment of President George W. Bush to create a
prescription benefit program for the elderly. This program
could take several different paths. There could be comprehensive Medicare reform with prescription coverage
and pharmaceutical care becoming a mandatory or optional benefit. There could also be just a prescription benefit passed for categorically defined individuals. Another
option could be a block grant program enabling states to
receive federal funds. States could have the flexibility in
choosing to establish a drug benefit or enhance pharmaceutical coverage with existing voluntary plans. Failure
of a political consensus among the President, Congress,
the pharmaceutical industry, pharmacies, and patients
could result in no additional prescription and pharmaceutical care coverage for consumers, at least until the
next presidential election in 2004.

The basic Medicare insurance program, which provides

benefits to consumers who are 65 or older, consists of
two components.
The hospital portion is Part A. It receives its name
from the fact that it is Part A of Title XVIlT of the

]
section of the legislation
Social Security A C ~ . [ ~his
covers inpatient hospitalization, critical access hospitals,
skilled nursing facilities, hospice care, and limited home
hea1th~are.I~
Critical access hospitals are small facilities
that provide limited outpatient care and inpatient services
to individuals in rural areas.
Most people pay for Part A during their working
years. They therefore receive this insurance benefit
automatically when the appropriate time comes. Employees and employers each pay 1.45% tax on all wages
and salaries.
The medical portion is Part B. and it is included
in the legislation as Part B of Title XVJU. It covers
medical services including physician care, outpatient hospitalization senlices. and selected medical activities not
covered in Part A, such as occupational and physical
therapists. This section will pay for diabetic supplies when
medically necessary.
The cost to the Medicare patient changes each year.
During the year 2001, it was $50.00 per month. This
charge is deducted from the recipients monthly Social Security check before it is received. The premiums
paid by participants represent 25% of the programs cost.
The remaining 75% is paid directly by a federal budget appropriation.

Healthcare C o w e ~ a ~Optio
e
Eligibility for Medicare enables individuals to select one
of a myriad of choices for receiving care.

The first Medicare health insurance is now called the

Original Medicare Plan.[61 This is a fee-for-service
plan. The provider charges a fee to the patient and or the
government each time the service is provided. This
arrangement is offered nationwide.
The federal government has authorized supplemental
insurance polices to aid in paying for services not covered
in the Original Medicare Plan. Up to ten supplemental
plans can be marketed by private insurance carriers. These
plans must be labeled Medicare Supplement Insurance.
There are high-cost and lower-cost policies. They differ in
the scope of coverage, deductibles, and copayments. Several of these optional programs have limited outpatient
prescription coverage. In addition to these supplements
that are also called Medigap policies, the standardized
benefits may also be sold as Medicare Select policies.
The Medicare Select benefits should be less expensive,
because the freedom-of-choice to choose providers is
limited to selected physicians and hospitals. Insurance
carriers may not add or subtract benefits to the

514

Medicaid and Medicare Pharmaceutical Programs

Supplement Insurance" policies. The only variable

allowed is the premium charged.

Extending Drug Coverage to All

Medicare Beneficiaries

Medicare + Choice

Extending the Medicare benefit package to include a

pharmaceutical care benefit could close a significant gap
in program coverage. The issues revolve around drug
costs and services. The various protagonists and antagonists all recognize the cost will be substantial to the
taxpayers and participants.[ lo]
Recently, prescription drug spending has far surpassed
growth in spending for other types of healthcare. The
rising expenditures have had a significant impact on Medicare beneficiaries, employers who offer retiree health
coverage, and on state governments providing drug coverage to the elderly."
The issues involved in providing drug and pharmaceutical care are numerous. They can be examined from the
financial and patient care perspectives, and by using management tools.

In 1997, legislation was passed to aid in diminishing

the growth of Medicare expenditures and provide more
options to participants in the healthcare plans. This legislative modification to a section of the Social Security Act is popularly known as Medicare+C or Medicare + Choice. These arrangements include the offering
of managed care plans (health maintenance, provider
sponsored, preferred provider, and point of service option), private fee-for-service plans, and medical savings accounts.

THEPRESENTSTATUSOF
DRUGCOVERAGE
Pharmaceuticals are covered for patients who are admitted
to hospitals for acute or chronic care. The law does not
provide for ambulatory drug coverage. Managed care
plans and some supplemental policies may offer a prescription benefit to its senior citizens. Medicare does not
directly pay for this coverage. Some Internet pharmacies
may attempt to lure unsuspecting patients to their sites
with special Medicare prescription plans. It is imperative
to recognize that the potential for scams on the elderly
exists because of their tendency to be trusting.[71
The issue of pharmacy benefits becomes more complicated and challenging to implement as each year passes.
Medicare will provide coverage for diabetic supplies of
glucose monitors, test strips, and lancets. Diabetic drugs
are not covered. The present official status is even difficult
for providing a simple answer to drug coverage.
Generally, Original Medicare does not cover prescription
drugs. However, Medicare does cover some drugs in certain cases such as immunosuppressive drugs (for transplant patients) and oral anti-cancer drugs."]
There are some Medicare Health Plans that cover
prescription drugs. You can also check into getting a
Medigap or supplemental insurance policy for prescription drug coverage. Medicaid may also help pay for
prescription drugs for people who are eligible.[']
Many former employers of retired workers provide a
level of voluntary prescription benefits in addition to
other retiree benefits.
Presently, pharmacists cannot directly bill for providing pharmaceutical services to patients.

Medicare participation
Most beneficiaries use drugs. The distribution of the use
of drugs is slanted toward patients with chronic conditions
of diabetes, hypertension, and cardiovascular diseases.
Adverse patient selection to participate is an important
issue, because there is an uneven distribution of drug use,
and patients must utilize medications over a long period
of time.

The financial conundrum. There are a myriad of

choices for funding the prescription benefit. Costs could
be financed as they are right now with "Part B" participation. Beneficiaries and the government contribute to
the benefit. Workers and retirees enrolled in employersponsored heath plans will have to be taken into account.
Beneficiaries who are on Medicaid will present issues that
the state and federal governments will have to resolve.
Recent drug benefit proposals for the low-income participants have indicated a strong preference for full or partial subsidies for the premium payments and cost sharing
for the prescriptions and pharmaceutical services utilized.
Drug benefit coverage
Legislation involving medical and hospital care has
always achieved a commitment to comprehensive care.
This obligation has not been honored when it comes to
providing drugs to patients. Employers and legislators
have fashioned creative reasons to provide less than comprehensive care. Since the past is considered prologue,
drugs will have to be considered from the vantage point of
false economy.

515

Medicaid and Medicare Pharmaceutical Programs

There are various ways to contain the drug benefit. The

drug benefit could be restricted by placing a cap on the
value of the benefits provided for a benefit period.
Another restraint would be to provide drug coverage after
a drug benefit deductible was exceeded or only provide
the benefit for catastrophic situations. This type of action
would save drug money; however, the overall costs for
healthcare would probably increase.
The pharmacy profession has recognized that the
benefits to society greatly exceed the cost of the drugs.
The benefits of the drugs and pharmacy care center
around an improved quality of life, a decrease in overall
healthcare expenditures, and an increased life span.[]

Administration of the drug benefit. Proposals being

discussed utilize the private-sector model of the Pharmacy Benefit Manager (PBM). Some proposals utilize
multiple PBMs for a geographic area, while others rely
on a single PBM to manage the program. The issue of
whether they will be merely a claims processor or have
additional responsibilities is varied. The remaining proposals require government management of the drug benefit. The managerial control would occur at the federal
or state level.
Additional tools to manage the pharmacy benefit.
Coordination of the Medicare benefit by implementing a
multidisciplinary approach to patient care should produce
a quality outcome for the beneficiary. From the pharmacy
perspective, numerous issues should be addressed.[13]
Some of the concerns include:
Formulary coverage. A drug formulary is an instrument that contains safe, effective, and affordable
medications designed to improve or maintain patient
health. The breadth and depth of coverage and the
ability to add drugs are imperative to maintaining a
workable drug formulary.
Pharmaceutical care and disease management. The
collaborative efforts of the interdisciplinary team of
pharmacists and other health professionals help to
ensure patients are utilizing medications appropriately.
Critical (clinical) pathways and drug step therapy.
These concepts can be effectively used to create a synergistic impact on improving the health of the elderly.
Critical pathways are designed to provide continuity of
care and decrease the fragmentation of services. Their
use helps guide the patient and family through the expected treatments and progress. It also increases the
satisfaction of patients, families, health professionals,
t141
and the various payers for healthcare services.

Step therapy for the drug treatment of patients creates a

road map to be used with various medications in order
to control the disease or medical condition. The initial step
is usually the most common one used in this situation.
More complex steps are not attempted to correct the patients situation until the earlier steps have failed.

Drug evaluation. Drug evaluation is an ongoing, systematic process designed to maintain the appropriate and
effective use of medications. It involves the review of the
physicians prescribing relationships, review of the pharmacists dispensing patterns, and patients use of medications. This evaluation goes by several names in different
healthcare setting^."^' The names include DUR (drug utilization review), DUE (drug use review), and MUE (medical use evaluation).
Resource-Based Relative Value System
Reimbursement for health services is extremely complicated. Providers want higher reimbursement, and payers
desire to reduce, maintain, or limit increases paid each
year. HCFA developed a methodology to deal with physician reimbursement and allow for an increase in payments
for physician services. It is a system based on approximately 7500 relative value service codes. These codes are
more complex than the approximate 450 Diagnosis Related Groups (DRG) used by hospitals in their Medicare
reimbursement. In addition to the service codes, the formula has a relative value unit (RVU) for practice expenses and a separate one for malpractice insurance. Added to
these components is a geographic practice cost index
(GPCI) for each defined work service area. The GPCI is
designed to take into account high- as well as low-cost
practice expenses and physician services as compared to
the national average for each constituent of the model. A
conversion factor (CF) is also part of the model. This variable is designed to maintain fiscal budget neutrality in the
event total payments exceed a certain monetary sum, determined by Congress, each year. The complexities involved can be understood more completely by checking
out the designated HCFA web site.[61
The model used to compute physician payment can be
expressed as:
Physician Payment
= [((RVU service activity x GPCI service activity)

+ (RVU practice expense

x GPCI practice expense)

+ (RVU malpractice expense

x GPCI malpractice expense)) x CF]

Medicaid and Medicare PharmaceuticalPrograms

516

The physician payment model is not perfect; however,

it represents a quantum leap forward compared to how
pharmacy practitioners are reimbursed. The reimbursement in many Medicare+Choice plans, in most state
Medicaid programs, and private PBM (third party)
arrangements fails to recognize that the costs for providing the pharmacy benefit changes at the practitioner
level. PBMs only recognize that the pharmaceutical
cost changes.

Medicare represents a federal entitlement program for

healthcare services that will continue to expand in
coverage of beneficiaries and benefits provided. Providers
will be continually challenged to maintain and increase
productivity, while payers explore innovative ways to pay
for services. A modification of the resource-based relative
value scale could be utilized in this endeavor. The drug
benefit is exceeding Congressional Budget Office estimates each year. Drug spending for beneficiaries is
projected to be $1,500,000,000,000 over the time period
2002-201 1 . The House of Representatives Budget
Resolution allocated $ 1 5 ? , 0 0 0 , 0 Q O , for
~ the drug benefit for the same peri~d."~'
The monetary difference is
approximately seven times greater than the major political
organizations have proposed. The gap between the estimate and the budget amount will require one of several
responses. Creative spin masters will have to explain the
continued lack of drug coverage, or there will be a final
recognition that drugs and pharmaceutical care represent a
cost-effective mechanism to aid in controlling healthcare
expenditures. "The key to an effective pharmaceutical
benefit is management," (and) "a well-trained, wellequipped pharmacist is critically important to the smooth
operation of a drug benefit."["'

EDlCAl
The 50 states, District of Columbia, Puerto Rico, Guam,
and the Virgin Islands and other territories all have
medical assistance (Medicaid) programs that vary somewhat but are within federal guidelines. States qualify
for federal reimbursement by agreeing to provide benefits to certain categories of needy persons who meet
the requirements of the block grant for (TANF), temporary assistance to needy families, and the subsequent aid
to families with dependent children (AFDC) programs,
and for blind and disabled persons receiving social security income.

The program covers children under six years whose

family income is no more than 133% of the federal
poverty level definition, pregnant women up to 133% of
the poverty level, some Medicare beneficiaries, and recipients of adoption assistance and foster care programs.
Medicaid covers virtually all outpatient and inpatient
health and rehabilitative services, home health, long-term
care, dental, prosthetic, pharmacy, and optical services
and goods. Pharmacy benefit rules state:
Prescribed drugs are simple or compound substances or
mixtures of substances prescribed for the cure, mitigation
or prevention of disease, or for health maintenance, which
are prescribed by a physician or other licensed practitioner of the healing arts within the scope of their
professional practice, as defined and limited by Federal
and State law (42 CFR 440.120). The drugs must be
dispensed by licensed authorized practitioners on a
written prescription that is recorded and maintained in
the pharmacists or practitioners re~ords."~'

While there are over 30 million beneficiaries enrolled

in Medicaid, not all of these persons were recipients of
services during any given year. Table 1 presents the utilization of various Medicaid services in fiscal year 1998.

Reimbursement
The Health Care Financing Administration (HCFA)
establishes the policies that individual State Medicaid
programs must adhere to. In the realm of prescription drug
reimbursement, rules were established in 1987 for multisource drugs. Upper payment limits based upon estimated

Table 1 Utilizing number of individuals of Medicaid services

in Ey 1998
Pharmaceuticals
Physicians
Hospital outpatient
LabK-ra y
EPSDT
Clinic
Dental
Hospital inpatient
Other practitioners
Personal support services
Family planning
Nursing facility
Home healthcare
ICF-mentally retarded
(From Ref. [ZO].)

19,337,543
18,554,746
12,157,729
9,380,689
6,174,628
5,285,415
4,965,202
4,408,162
4,341,915
3,108,432
2,011,124
1,645,728
1,224,714
126,490

Medicaid and Medicare Pharmaceutical Programs

acquisition costs (EAC) were established. For drugs certified by the FDA as being interchangeable, if the prescriber writes on the face of the prescription: brand
necessary or medically necessary, the patient can
receive the branded product instead of the generic equivalent product. For 1998, HCFA spent $13.52 trillion for
19.3 million recipients which is about $700 per recipient
that year.
The top ten states in prescription expenditures for 1998
(in descending order) were California, New York, Florida,
Texas, Ohio, Illinois, Pennsylvania, Massachusetts, North
Carolina, and New Jersey. The ten lowest expense states
were Oklahoma, Arizona. Tennessee, Wyoming, North
Dakota, South Dakota, Alaska, Nevada, Hawaii, and
District of Columbia. For all states, drugs and related
services consumed 9.5% of the total Medicaid budget.
Because of this more than $13 trillion expenditure, in
1990, Congress considered alternative means to reduce
this expense. The result was a compromise where in
exchange for Medicaid formularies to be open to all
drugs, manufacturers agreed to agree to a rebate program with HCFA in the OBRA 1990 legislation. Rebates were to be a minimum of 10% of that states purchases from a company. OBRA was amended in 1992,
and today, manufacturers pay 15.1% of the average manufacturers price back to the state for innovator (singlesource) products, and 11% is returned for generic, multisource products. [ 2*I
To give one a feeling for the quantities involved, the
total rebate for 1998 was $2.5 billion. While all drugs
should be available, state Medicaid agencies may restrict
availability of certain drugs of limited value, regarding
safety, effectiveness, or clinical outcome if the drug may
be obtained through the prior approval procedure. Other
drugs may be excluded completely if they are:
For anorexia, weight gain, fertility, hair growth, cosmetic effect, smoking cessation, or symptomatic relief
of cough or cold.
0
Vitamins or minerals or OTC drugs (fluorides and
prenatal vitamins excluded).
0
Drugs requiring monitoring to be obtained from the
manufacturer.
* Barbiturates or benzodiazepines.
0

A significant component of the Medicaid drug program

is a Drug Utilization Review (DUR) activity, which is
defined as a structured and continuing program that reviews, analyzes, and interprets patterns of drug usage in
a given healthcare environment against predetermined
standards. This is conducted for two purposes: to improve
the quality of care and to assist in containing costs. OBRA

517

requires that states provide prospective DUR and retrospective DUR programs. The prospective DUR activity
is performed at the time of dispensing.[221
As is the case of an HMO patient presenting a card at
the pharmacy, the Medicaid patient does the same thing.
Each state decides whether it will have a patient copayment, and if so, its amount. About 15 States have no
copayment requirement, and the others charge between 50
cents and $3.00 per prescription.
The pharmacy is paid a dispensing fee that ranges
between $3.00 and $5.50 per prescription, depending
upon the state. The pharmacy is reimbursed the wholesale
price of the drugs minus a discount, which is a percentage
reduction from the sticker price (called AWP or
average wholesale price) which is higher than the actual
price paid by most pharmacies due to quantity discounts,
direct purchases from manufacturers, and the taking advantage of deals. The discount averages about 11 or
12% of the average wholesale price. This brings the ingredient reimbursement more in line with the actual price
paid by the pharmacy.
For an example, let us consider a drug where the AWP
is $60.00. The patient paid $3.00, and the pharmacy will
be reimbursed $60.00 less 12%, which equals $52.80 less
the $3.00 patient copayment or $49.80 by that state
Medicaid agency. In addition, the pharmacy will receive
$4.00 as a dispensing fee.
Because of budget problems in some states from timeto-time, limitations have been implemented on occasion.
Some states have limited the number of prescriptions per
month for limited periods or established caps on the value
of the benefits. Usually, these have been lifted when the
budget situation improved, especially because there is no
evidence that such restrictions are cost-effective overall,
and, in fact, there is considerable suspicion that patients
might not get needed drugs, resulting in potentially massive hospital or other costs.
With such a huge price tag, HCFA administrators and
legislators are always searching for means to reduce costs.
Some relief has come from the prior authorization program as well as from a mandatory generic dispensing
policy in many states, but additional savings are still
desired. There has been discussion about placing recipients in managed care plans that are capitated and having the practitioners control utilization with actual incentives. Some states have asked for supplemental rebates
that provide a discount well beyond the OBRA 1990
dictated amount.[231
Health economists continue to advocate greater emphasis on prevention, screening, patient education, wellness education with emphasis on nutrition, smoking, and
alcohol use reduction, avoidance of substance abuse, and

Medicaid and Medicare Pharmaceutical Programs

51s

prenatal care as examples of strategies to reduce illness

trauma and cost throughout life. Perhaps enrollmcnt in
capitatcd managed care organizations can provide the
environment and suitable incentives for greater cost
savings in the future.

12.

13.

14.
1. Wright. J.W. 2001 New York Times Almanac; Penquin:
New York, 2000: Vol. 153.
15.
2. Phavnzacj and the US Health Care Sjstem, 2nd Ed.;
Fincham, J., Wertheimcr, A,, Eds.: Pharm. Products
Press: Hinghamton, New York, 1998; Vol. 34.
16.
3. h t t p :// w w w . M E D I C A R E . G O V/3 5 / m i l e s tones .a s p
(accessed April 2001).
4. Social Security Act. http://www.ssa,gov/OP_Horne/ssact/
17.
comp-toc.htm, accessed April 2001.
5 . Medicare and You 2001, HCFA-10050; Health Care
Financing Administration: Maryland, 2000; Vol. 5; I -73.
18.
6. Medicare and You 2001, HCFA-10050; Health Care Financing Administration: Maryland: 2000;Vol. 14; 1-73,
7. http://www.MEDICARE.GOV/publications/pubs/pdf/19.
2049fina.pdf File: /publications/pubs/pdf/2049fina.pdf.
8. Medicare 2000:35 Years of Improving Americas Health
20.
and Security, pp. 2, July 2000,Medicarc factl0.pdf http://
www.medicare.gov/FAQs/Top20.asp, April 15, 2001.
9. Medicare 2000:35 Years of Improving Americas Health
21.
and Security, pp. 2,July 2000,Medicare factl0.pdf http://
www.medicare.gov/FAQs/Top20.asp,
April 15, 200I .
10. Laying the Groundwork for a Medicare Prescription Drug
Benefit, Statement of Dan L. Crippen, Committee on Ways
22.
and Means, Subcommittec on Health, U.S. House of Representatives, March 27, 200I .
23.
11. Laying the Groundwork for a Medicare Prescription Drug
Benefit, Statement of Dan L. Crippen, Committee on Ways

and Means, Subcommittee on Health, U.S. House of Reprcsentatives, March 27, 2001.
R x price controls likely unless manufacturers help curb
costs, Vt. Gov says; McCaughan, M., Ed.; The Pink Sheet
2001. 63 (14); 6.
Where W e Stand: Medicare Pre.ccription Drug Coverage;
Stables, C., Ed.; Academy of Managed Care Pharmacy:
Virginia, 1999; 1 - 12.
Sapienza, A.;
Broescker. A. Health Care Professionals and
Interprofessional Care. In Introducfion to Health Care
D e l i v e p A Primer for Pharmacists; McCarthy, R., Ed.;
Aspen Publishers, Inc.: Maryland, 1998; 48-59.
Drug Use Evaluation; The Academy of Managed Care Pharmacy. http://amcp.org/public/pubs/concepts/drugusc.html
(accessed March 2001).
http: // www .hcfa.gov/ stats/pufiles. htm#rvu; http: //www.
MEDICARE.GOV/publicati~~ns/pubs/pdf/204Yfina.pdf
File: /publications/pubs/pdf/2049fina.pdf.
Medicare PBMs could offer loose and .tight Rx options-Rep.
Johnson; McCaughan, M., Ed.; The Pink
Sheet 2001, 63 (14); 9 10.
http://www.healthnewsdaily.com/rs/channels/fdc/HND/
Current + Articleshnd + pink/stories/0425p2.asp.
Pharmaceutical Benefits Under Stat<. Medical Assistance
Programs, 1999; National Pharm. Council: Reston, Virginia, 2000; Vol. 4.8.
Pharmaceutical Benefits Under State Medical Assistance
Programs, 1999: National Pharm. Council: Reston, Virginia, 2000;Vol. 4.12.
Pharmaceutical Benefits Under State Medical Assistance
Programs, I Y Y Y ; National Pharm. Council: Reston, Virginia. 2000:4.32.
Wertheimer, A,; Navarro, R. M m a g e d Cure Pharmacy:
Principles and Practice; Pharm Products Press: Binghamton, New York, 1999; Vol. 232.
Sultz. H.:Young, K. Healthcare USA; Aspen: Gaithersburg, Maryland, 2001 ; 272.

Poison Information Pharmacy Practice

governed by a board of directors elected by ABAT

membership from among its diplomates.
All ABAT functions are undertaken in accordance with
ABAT bylaws and the bylaws of AACT; these bylaws and
all regulations and procedures are promulgated by ABAT.
ABAT is a not-for-profit organization. No member of
ABAT receives or derives any profit from the operation
of ABAT and no part of the net income of ABAT benefits any individual member. ABAT is not involved in
authorizing or designating any political lobby action.
The principal office of ABAT is usually established in
the city of the residence of the president.

769

ical toxicology. Scholastic course work is not

considered to be professional experience.
Because the American College of Medical Toxicology
and the American Board of Veterinary Toxicology are
responsible for certification in their respective areas,
applicants holding the Doctor of Medicine, Doctor of
Osteopathy, or Doctor of Veterinary Medicine degree
are not eligible to sit for the ABAT examination.

Applicants must meet the following initial criteria to become a candidate for examination:

2. Applicants must complete at least 12 months of

postdoctoral training (i.e., residency or fellowship)
in clinical toxicology or a closely related field. Applicants without postdoctoral training must have a
minimum of at least three years of professional experience related to applied clinical toxicology after
completion of their doctoral degree. To be prepared
for the examination, candidates should have considerable clinical experience and an understanding
of the clinical and environmental factors associated with various types of toxicological problems.
Examples of activities related to the practice of
applied clinical toxicology include consulting with
medical personnel on patient care issues; having
administrative responsibility for a poison control
center with consultative responsibilities; rendering
opinions on product toxicity; teaching clinical toxicology to students, practitioners, or colleagues;
collaborating with medical toxicologists; and conducting research in applied clinical toxicology.
3. Applicants must demonstrate experience in all the
areas of clinical, research, and teaching activities
and leadership. An abundance of experience in
one area will not substitute for lack of experience
in another.
4. Applicants holding a degree in a healthcare profession in which licensing is required must be in
good standing with the appropriate jurisdictional
board and must be eligible for, or possess, a valid,
unrestricted license to practice. A copy of the
license must accompany the application.
5 . Applicants must be members in good standing
of the American Academy of Clinical Toxicology at the time of their application.

1. Applicants must be a graduate of a college or

university with an earned doctoral degree in a
biomedical discipline. Applicants without doctoral
degrees must possess a baccalaureate degree in a
health science discipline, such as pharmacy or
nursing, followed by a minimum of five years of
full-time urofessional exuerience in auulied clin-

Following receipt of the completed application and application fee, the candidate's submission is reviewed by
the Credentialling Committee. The committee uses a
standardized credential review document among the
aunlication reviewers. A formal letter from the uresident

ABAT was created as a not-for-profit organization for

the unique purpose of fostering the development of clinical toxicology among the nonphysician, nonveterinarian
members of the American Academy of Clinical Toxicology by:
Advancing the science, study, and practice of clinical
toxicology.
Improving the quality of clinical toxicology consultation available to the public.
Establishing and maintaining standards of excellence
for nonphysician practitioners by developing and administering examinations, as well as other criteria, for
the certification and recertification of these practitioners in clinical toxicology.
Granting certificates and other forms of recognition to
professionals who demonstrate exceptional ability in
clinical toxicology.
Maintaining a registry of ABAT diplomates and, upon
request, furnishing lists of ABAT diplomates to the
public, governmental agencies, healthcare professionals, and educational institutions.

BAT Certification Examination

Poison Information Pharmacy Practice

770

of ABAT will inform the candidate of the committees

decision, and if required. will list areas of improvement
the committee felt would allow the candidate to successfully pass credential review on a subsequent submission. Once credentialled, an applicant must take the exam
within two examination cycles.

Iicat io

A combined application and testing fee of $400, made

payable to the American Board of Applied Toxicology,
must accompany the application. If credentialling is
denied for any reason, the $300 portion for the examination will be refunded.

(3)

on poison control centers, $7 in medical costs are

saved. The average cost of a poisoning exposure
call is $32, while the average cost if other parts
of the medical system are involved is $932. Over
the last 2 decades. the instability and lack of
funding has resulted in a steady decline in the
number of poison control centers in the United
States. Within just the last year, 2 poison control
centers have been forced to close because of
funding problems. A third poison control center
is scheduled to close in April 1999. Currently,
there are 73 such centers.
Stabilizing the funding structure and increasing
accessibility to poison control centers will increase the number of United States residents who
have access to a certified poison control center,
and reduce the inappropriate use of emergency
medical services and other more costly healthcare services.

finitio
At the second session
Begun and held at the City of Washington on Monday,
the twenty-fourth day of January, two thousand
An Act
To provide assistance for poison prevention and to
stabilize the funding of regional poison control centers.
Be it enacted b j the Senate and House of Representatives of the United States of America in Congress
assembled,
ec.

ort Title

This Act may be cited as the Poison Control Center

Enhancement and Awareness Act.

Congress makes the following findings:

(1) Each year more than 2,000,000 poisonings are

reported to poison control centers throughout the
United States. More than 90 percent of these poisonings happen in the home. Fifty-three percent
of poisoning victims are children younger than 6
years of age.
Poison
control centers are a valuable national
(2)
resource that provide lifesaving and cost-effective public health services. For every dollar spent

In this Act, the term Secretary means the Secretary of

Health and Human Services.

(a) IN GENERAL-The Secretary shall provide coordination and assistance to regional poison
control centers for the establishment of a nationwide toll-free phone number to be used to access
such centers.
(b) RULE OF CONSTRUCTION-Nothing
in this
section shall be construed as prohibiting the establishment or continued operation of any privately funded nationwide toll-free phone number
used to provide advice and other assistance for
poisonings or accidental exposures.
(c) AUTHORIZATION OF APPROPRIATIONSThere is authorized to be appropriated to carry out
this section. $2,000,000 for each of the fiscal years
2000 through 2004. Funds appropriated under this
subsection shall not be used to fund any toll-free
phone number described in subsection (b).

(a) IN GENERAL-The
Secretary shall establish a
national media campaign to educate the public and

Poison Information Pharmacy Practice

healthcare providers about poison prevention and

the availability of poison control resources in local
communities and to conduct advertising campaigns concerning the nationwide toll-free number
established under Section 4.
(b) CONTRACT WITH ENTITY-The
Secretary
may carry out subsection (a) by entering into contracts with 1 or more nationally recognized media
firms for the development and distribution of
monthly television, radio, and newspaper public
service announcements.
(c) AUTHORIZATION OF APPROPRIATIONSThere is authorized to be appropriated to carry
out this section, $600,000 for each of the fiscal
years 2000 through 2004.

(a) REGIONAL POISON CONTROL CENTERSThe Secretary shall award grants to certified regional poison control centers for the purposes of
achieving the financial stability of such centers,
and for preventing and providing treatment recommendations for poisonings.
(b) OTHER IMPROVEMENTS-The Secretary shall
also use amounts received under this section to-

771

State government as having in effect standards for certification that reasonably provide
for the protection of the public health with
respect to poisoning.
(d) WAIVER OF CERTIFICATION
REQUIREMENTS-

(1) IN GENERAL-The Secretary may grant a

waiver of the certification requirement of
subsection (c) with respect to a noncertified
poison control center or a newly established
center that applies for a grant under this
section if such center can reasonably
demonstrate that the center will obtain such
a certification within a reasonable period
of time as determined appropriate by the
secretary.
( 2 ) RENEWAL-The
Secretary may only
renew a waiver under paragraph (1) for a
period of 3 years.

( I ) The center has been certified by a profes-

(e) SUPPLEMENT NOT SUPPLANT-Amounts

made available to a poison control center under
this section shall be used to supplement and not
supplant other Federal, State, or local funds
provided for such center.
( f ) MAINTENANCE OF EFFORT-A
poison control center. in utilizing the proceeds of a grant
under this section, shall maintain the expenditures of the center for activities of the center at a
level that is not less than the level of such expenditures maintained by the center for the fiscal
year preceding the fiscal year for which the grant
is received.
(g) MATCHING REQUIREMENT-The
Secretary
may impose a matching requirement with respect
to amounts provided under a grant under this
section if the Secretary determines appropriate.
(h) AUTHORIZATION OF APPROPRIATIONSThere is authorized to be appropriated to carry
out this section, $25,000,000 for each of the fiscal
years 2000 through 2004.

sional organization in the field of poison

control, and the Secretary has approved the
organization as having in effect standards for
certification that reasonably provide for the
protection of the public health with respect
to poisoning; or
The center has been certified by a State government, and the Secretary has approved the

CHRIS: U.S. Coast Guard chemical hazard response

information.

(1) Develop standard education programs;

( 2 ) Develop standard patient management protocols for commonly encountered toxic
exposures;
(3) Improve and expand the poison control data
collection systems;
(4) Improve national toxic exposure surveillance;
and
( 5 ) Expand the physiciadmedical toxicologist
supervision of poison control centers.
(c) CERTIFICATION-Except as provided in subsection (d), the Secretary may make a grant to a center
under subsection (a) only if-

(2)

772

Poison Information Pharmacy Practice

Dolphin Software: Over 160,000 material safety data

sheets.

RTECS from NIOSH: Registry of the toxic effects of over

142,000 substances.

Drugdex: Extensive pharmaceutical information.

Safetydex: Over 8000 hospital-specific material safety

data sheets.

Drug-Reax: Drug interaction information on over 8000

pharmaceuticals.

Tomes: Medical and hazard information for chemicals.

Fisher ScientificlACROS Organics MSDS: Over 18,000

material safety data sheets for pure chemicals. Available
in 5 different languages.
Hazardtext: Emergency response information for hazardous material emergencies.
HDSB from NLM: Health and environmental effects of
over 4500 toxic chemicals.
Identidex: Tablet and capsule identification system
Index Nominum: International drug directory.
Infotext: Environmental health and safety information
directed toward occupational hygienists.
IRIS: U.S. Environmental Protection Agency health risk
assessment information for over 450 chemicals.
LOLI: Environmental, international, and state regulations
on chemicals maintained by ChemAdvisor.
NAERG: 1996 North American Emergency Response
Handbook.
NIOSH Pocket Guide: Occupational information including exposure limits, incompatibilities, and reactivities.

General ~oxicology
Poisoning and Toxicology Compendium with Symptoms Index, Jerrold B. Leikin, and Frank P. Paloucek;
Lexi-Comp, Hudson, Ohio, 1998.
Clinical Management of Poisoning and Drug Overdose, Third Edition; Lester M. Haddad, Michael W.
Shannon, and James F. Winchester; WB Saunders,
Philadelphia, Pennsylvania, 1998.
Goldfranks Toxicologic Emergencies, Sixth Edition;
Lewis R. Goldfrank, Neal E. Flomenbaum, Neal A.
Lewin, Richard S. Weisman, Mary Ann Howland, and
Robert S. Hoffman; Appleton and Lange, Stamford,
Connecticut, 1998.
Toxicology of the Eye, Fourth Edition; W. Morton
Grant, and Joel S. Schuman; Charles C Thomas,
Springfield, Illinois, 1993.
Casarett and Doulls Toxicology, Sixth Edition; Curtis
D. Klaassen; McGraw-Hill, New York, New York,
2001.

aterials Toxic01 ogy

NJ Hazardous Substances Fact Sheets: Employeeoriented information on 700 hazardous substances developed by the New Jersey Health Department.

Hazardous Materials Toxicology: Clinical Principles of

Environmental Health, Second Edition; John B. Sullivan,
Jr. and Gary R. Krieger; Williams and Wilkins, Baltimore, Maryland, 2001.

OHM/TADS: Physiochemical and toxicological information on 1400 substances. Includes oils and other environmental hazards.

Saxs Dangerous Properties of Industrial Materials,

Eighth Edition; Richard J. Lewis, Sr.; Van Nostrand
Reinhold, New York, New York, 1992.

Poisindex: Ingredient and clinical toxicology management information on over 1 million substances.

Occupational, Industrial, and Environmental Toxicology;

Michael I. Greenberg, Richard J. Hamilton, and Scott D.
Phillips; Mosby, St. Louis, Missouri, 1997.

RegsLink: Access to federal and state chemical regulatory

information.
Reprorisk: Contains 4 databases on reproductive risk
information.

Proctor and Hughes Chemical Hazards of the Workplace, Fourth Edition; Gloria J. Hathaway, Nick H. Proctor, James P. Hughes, and Michael L. Fischman; Van
Nostrand Reinhold, New York, New York, 1996.

Poison Information Pharmacy Practice

s
Handbook of Mushroom Poisoning: Diagnosis and
Treatment; David G. Spoerke and Barry H. Rumack;
CRC Press, Boca Raton, Florida, 1994.
AMA Handbook of Poisonous and Injurious Plants; Kenneth F. Lampe and Mary Ann McCann; American Medical Association, Chicago, Illinois. 1985.

Breastfeeding: A Guide f o r the Medical Profession, Fifth

Edition; Ruth A. Lawrence and Robert M. Lawrence;
Mosby, St. Louis, Missouri, 1999.

773

Handbook of Chemical and Biological Waifare Agents;

D. Hank Ellison; CRC Press, Boca Raton, Florida, 2000.
Militaiy Chenzical and Biological Agents; James A.F.
Compton; Telford Press, Caldwell, New Jersey, 1987.
Chemical Warfare Agents; Satu M. Somani; Academic
Press, San Diego, California, 1992.

eneral Toxicol
edical and Clinical Toxicology
Guide to the ~ n t ~ r n e t

A Reference Guide to Fetal and Neonatal Risk Drugs in

Pregnancy and Lactation, Fourth Edition; Georald 6.
Briggs, Roger K. Freeman, and Sumner J. Yaffe; Williams and Wilkins, Baltimore, Maryland, 1994.

http://www.swmed.edu/toxicology/toxlinks.html

Snake Venom Poisoning, Second Edition; Findlay E.

Russell; Scholium International, Great Neck, New York,
1983.

http://www.ncbi.nlm.nih.gov/pubmed/

Herbal Drugs and Phytoplzarnzaceuticals: A Handbook

for Practice on n Scientific Basis; Norman Grainger
Bisset; Medpharm, Stuttgart, Germany, 1989.
The Lawrence Review of Natural Products; Facts and
Conzparisons; Facts and Comparisons, St. Louis, Missouri. 1999.

Disposition of Toxic Drugs and Chemicals in Man,

Fourth Edition; Randall C. Baselt and Robert H. Cravey; Chemical Toxicology Institute, Foster City, California, 1995.

Textbook of Military Medicine Part I-Medical Aspects of

Chemical and Biological Warfare; Russ Zajtchuk, Editor;
Department of the Army, Bethesda, Maryland, 1997.
Chemical Warjare Agents; Timothy C. Marrs, Robert L.
Maynard and Frederick R. Sidell; John Wiley and Sons,
New York, New York, 2000.

This
PIC
logy
logy

site provides a single access point to numerous

Web sites, journals that publish clinical toxicopapers, and other links to important clinical toxicoinformation.

This site provides online MedLine searching capabilities.

~ a t i Q nA
a c~ a d e ~ y
http://www.nap.edu/catalog/6035.html
Catalog site for publications from the National Academy
of Sciences.
National Library of
http://www.nlm.nih.gov
Entry point for the National Library of Medicine including general information, databases, and photographic archives.
National Library of
Internet Grateful Med
http://igm.nlm.nih.gov/
The Internet Grateful Med Web site provides a variety
of database accesses to a variety of searches including
MEDLINE, AIDS line, AIDS drugs, AIDS trials, Chemical Identification, NIH Clinical Alerts, and a variety of
other very useful access sites.

Library of Medicine
http://sis.nlm.nih.gov/ToxSearch.htm
This provides a variety of information on toxicology and
environmental health with searches and links to a variety
of important organizations.

774

Poison Information Pharmacy Practice

roject
http://www.npac.syr.edu/projects/vishuman/
VisibleHuman.html
The Visible Human Project is a three-dimensional representation of the male and female body. The current phase
deals with transverse CT, MR, and cryosection images at
1-mm intervals.

rotox-An

online repro

http://www.reprotox.org
Reprotox provides current assessments on potential
harmful affects of environmental exposure to chemicals and physical agents on human pregnancy, reproduction, and development. This online source requires
a subscription.

TOXNET ToxLine
http://toxnet.nlm.nih.gov/servlets/simple-search
This site provides free access for tox line searches.
These include access to HSDB (Hazardous Substances
Data Bank), CCRIS (Chemical Carcinogenesis Research
Information System), RTECS (Registry of Toxic Effects
of Chemical Substances), GENE-TOX [Genetic Toxicology (Mutagenicity) Data], IRIS (Integrated Risk
Information System). TRI (Toxicology Releases Search),
Chem-info (Chemical information identification), and
many others.

ealth ~mforrnat~om

http://sis.nlm.nih.gov/tehipl.htm
This is the toxicology section of the National Library of
Medicine that has a wealth of information that is searchable in many databases.
Env~ronrne~ta~
Che

ata and ~m~orrnatio~

http://ecdin.etomep.net/Ecdin/E-hinfo.html
This is a factual database created by the European Commission, Joint Research Centre at the Ispra (I) site. It
contains a list of chemical information for each chemical
listed. One of its sections is PHATOX (Pharmacological
and Toxicological) data which includes health evaluations,
toxicological data, epidemiological data, and health
hazard evaluations.

o ~ s o n ~n~orrnatiQn
i~~
http://www.mic.ki.se/Diseases/c21.613.html
The site provides access to many links with detailed information on a variety of poison issues including: general;
bites and stings; food poisoning; gas poisoning; plant
poisoning; lead, iron, mercury, cadmium. nickel, and drug
poisoning; and hazardous substances. There are many
pictures and multiple links.

http://www.cponline.gsm.com
Search engine for commonly prescribed drugs with dosages, indications, interactions, pharmacokinetics, costs,
and more.

http://odp.od.nih.gov/ods
This Web site provides information regarding dietary
supplements.
atabase at Pharrnac~ut~ca~
~ m f o r ~ a t i oAssociation
n
http://www.pharminfo.com
Information about pharmaceutical industry drugs and research from the Internet service PharmInfoNet.

http://www .mninter.net/-publish/
This is a comprehensive collection of drugs of abuse.
Although the information is somewhat basic it is very
comprehensive.

http://www.holisticmed.com/www
This is an interesting and very useful site that provides
a lot of information on holistic medicines and alternative therapies.

erreal
http ://www .hyperreal.org
Important site that includes drugs of abuse primarily involving the rave scene.
ide-The

Virtual

http://www.internets.com/mednets/stoxicology
.htm

http://www-sci.lib.uci.edu/HSG/Pharmacy.html

This site provides a list of links to various toxicological sites.

Access to Martindales pharmacy center for drug

information.

Poison Information Pharmacy Practice

Pharmacy (Medicine, Biosciences)

http://www.pharmacy.org
This site contains many links to pharmacy-related resources, including schools of pharmacy, online journals,
CME, and societies.
PharmWeb
http://www.pharmweb.net
This is a searchable site from the U.K. with information
for the patient and health professional.
X Drug Compendium Program
http://www 1.mosby.com/Mosby/PhyGenRx
A comprehensive listing that is searchable for generic or
brand names and by drug category.

775

This a searchable Web site that contains information

and photographs of various fungi, both poisonous and
nonpoisonous.

Medical Botany Library

http://www .floridaplants.com/mpois.htm
Information on poisonous plants and mushrooms from
around the world.
Medicinal and Poisonous Plant
http://www .inform.umd.edu/EdRes/Colleges/LFSC/
life-sciences/.plantbiology/Medicinals/medicinals,
htm
Information and links on poisonous and medicinal plants
from the University of Maryland.

RxList Internet Drug Name Category

Cross Index
http://www.rxlist.com
Searchable database of 4000 prescription and OTC drug
products designed for the lay public.

NAMA-North American Mycologica~A s s o c i a ~ i o ~

http://Sorex.tvi.cc.nm.us/namalpoison/poison.htm

ScripWorld Pharmaceutical News

http://www.pj bpubs.co.l;uk/acrip/scrhome.html
Scrip is the only international, twice-weekly newsletter
reporting on the pharmaceutical sector, covering prescription and OTC medicines and biotechnology news.

Natural Toxins FDA

Natural Toxins

American Zoo and Aquarium Association

http://www.aza.org
Information and pictures of toxic animals. Order form to
obtain the Antivenom Index which is $20-30 in the
publications area.
Antivenom Handbook for Australia
http://www .wch.sa.gov.au/paedm/clintox/cslb-index.htm1
This site has the handbook for a variety of poisonous
animals from Australia. See the preceding site for North
America.

This is a very useful site that presents various mushroom

toxidromes. There is also a case registry report form that
can be downloaded and reported to NAMA.

http://vm.cfsan.fda.gov/-mow/toxintoc.html
Lists information on fish, shellfish, mycotoxins, and many
other natural toxins from the FDA.

Poison Information Centre--Singapores

Ministry of Health

http://www.gov.sg/health/mohiss/poison/index.html
Singapores poison information center provides great information about natural toxins in their region of the world.
The site also has pictures of many creatures.

Poisonous Plant Database (Plantox)

http://vm.cfsan.fda.gov/-dj
w/readme.html
The Poisonous Plant Database is a set of working files of
scientific information about the animal and human
toxicology of vascular plants of the world. The initial
files were created in 1994, and are updated periodically.
Poisonous Plants Web Page of Cornell ~ n ~ ~ e ~ s i ~ y

Foodborne Pathogenic Microorganisms and

Natural Toxins Handbook
http://vm.cfsan.fda.gov/-mowlintro.
html
This is a site from the U.S. FDA Center for Food
Safety and Applied Nutrition. Useful information on
mushroom toxidromes.
Fungi Images on the Net
http://isa.dknet.dkl-pip1833/mushimage/

http://www.ansci.cornell.edu/plantslplants.html
This site provides information and pictures of poisonous
plants. This site also lists veterinary species of interest.

The Poisonous Plant Guide

http:l/www .ednet.ns.ca/educ/museum/poisonl
ppguide. htm
An illustrated guide to some common poisonous plants in
Nova Scotia including algae, fungi, and leafy plants.

Poison Information Pharmacy Practice

776

them. However, the results of a search of the CBIAC site

itself leads to documents that have unrestricted access.

Anthra~Vaccine ~ m m u n i ~ a t ~Program
on
http://www .anthrax.osd .mil/
The U.S. militarys Web site for information related to
the anthrax vaccination program. Includes information
about anthrax and its use as a biological weapon, Q
and A about the vaccine, a newsletter, and a section
on related links.
oly Chemical and
http:/www.calpoly.edu/-drjones/chemwarf.html
A page created by the students in the 1996 spring semester
class of Chemistry 405. Contains documents on the history
of chemical and biological warfare in ancient and modern
times. Also contains sections on the nerve and riot control
agents. Even shows the stepwise process of synthesizing
several of the nerve agents.

GDC Bioterrorism re pa redness and

http:/www.bt.cdc.gov/
The CDC has dedicated a specific page within their Web
site on bioterrorism. The page has two important sections
for poison centers. The first is the Biological Agents
section with a FAQ (frequently asked questions) document, Fact Sheet, Case Definition, and CDC Prevention
Guidelines on a specific biological agent. The other
section is the Learning Resources section. Included in this
area are CDC resources such as articles on bioterrorism
from the CDC Journal of Emerging Diseases, official
statements on bioterrorism, a video library, and news and
events. The video library contains two sets of tapes, the
six-tape set from the September 1998 Medical Response
to Biological Warfare and Terrorism and one tape from
the Public Health Ground Rounds-Bioterrorism:
Implications for Public Health. Watching the tapes requires the
use of the Real Player program that is downloadable from
the site.
efense ~ n f ~ r m a t i o n
http:/www .cbiac.apgea.army.mil/
The center is located at the Battelle Memorial Institute
and serves as the Department of Defenses focal point
for information related to chemical warfarelchemical and
biological defense. As part of its services, it offers an
excellent search engine for the CBIAC site as well as
password-protected bibliographic database (you can apply
for a password online). Articles identified by a search in
the bibliographic database are available only through the
Defense Technical Information Center and have to be
special ordered, which means setting up an account with

FE
Response Information System (
http://www.rris.fema.gov/
Although this site is named Rapid Response Information System and it has a wide range of resources, it
usually takes multiple screens to get to the information.
The site has several sections including a relatively
complete list of equipment with descriptions and vendors;
an extensive list of monographs on nuclear, chemical, and
biological agents; and a reference library with links to
other sites and documents. There is also a symptombased search engine that will find any symptom or
group of symptoms names in the monographs.
Emer~ency~ET
http://www .emergenty . c o d
Web page for the Emergency Response and Research
Institute. The site has separate pages for different EMS
topics including Infectious Diseases and Chemical/
Biological Terrorist Attack. The latter page contains a
lesson plan for EMTs and First Responders regarding
NBC incidents.
edical NBC Online Information Server
http://www.nbc-rned.org
Developed by the U S . Surgeon General to provide a
learning and reference resource for medical NBC
information. Although the site has been developed for
U S . Army medical personnel. the site makes available
many NBC health-related resources to any practitioner
with access to the Internet. Site includes a news section,
medical references (e.g., Army medical field manuals
such as FM8-9(B) and the July 1998 edition of Medical
Management of Biological Casualties), video and audio
clips, training and calendar sections, and a search engine.
Also there are numerous links to other NBC sites and
many governmental and nongovernmental agencies
involved with NBC information.
itretek Systems-Chemical,
and Nuclear Systems
http://www .mitretek.org/mission/envene/nbc.html
This site has excellent monographs on the chemical and
biological warfare agents (see Background on Chemical
and Background on Biological Warfare Agents). The
monographs are detailed with either chemical structures
of the chemicals or toxins or photographs of the biological organism. Many other excellent references and
documents related to chemhioterrorism can be found
as either onsite documents or links.

777

Poison Information Pharmacy Practice

utbreak
http://www.outbreak.org/
Outbreak is an online information service that addresses emerging diseases for the health professional
and the interested layperson. It attempts to provide a
worldwide collaborative database to collect information
about possible disease outbreaks. There are registered
user and nonregistered user portions of the site. There
is the usual list of biological agents found at other sites
with fact sheets for each one, but in addition, there are
reports from ProMED about any past outbreaks of the
disease. ProMED (Program for Monitoring Emerging
Diseases), a list server from the Federation of American Scientists, provides information on emerging diseases via e-mail to its subscribers. Outbreak maintains
a library of information about past outbreaks reported
in ProMED.
Sarin Nerve Gas
http://www .geocities.com/CapCanaveral/Lab/7050/
Brief but informative site on sarin nerve agent. Describes sarin, its history as a terrorist agent. protective
equipment, and dosage effects. Nice bibliography and
links to other sites with reference documents on sarin.

nstitute of Chemical
http://chemdef.apgea.army .mil/
The Armys center for chemical defense, USAMRICD
Web page has several sections of interest. The first in
an extensive bibliography by year of all the book
chapters and published scientific papers produced by
the USAMRICD staff. The next section of importance
is a downloadable version of the Institutes 1995 edition
of the Medical Management of Chemical Casualties
handbook. The links section may not be functioning,
but could be a good gateway to other sites.

esearch Institute of Infectious

http://www.usamriid.army
.mil/
This is the home page of USAMRIID and a good site for
two sources of information. First under its publications
section, you can find downloadable versions of the
Armys reference books, FM8-9 Handbook on The
Medical Aspects of NBC Defensive Operations, Medical
Management of Biological Casualties (July 1998 edition),
and Defense Against Toxin Weapons. The second section
of importance is the Continuing Education section which
contains the text and PowerPoint slides used in the Armys
Medical Management of Biological Casualties course.

ibition
http://www.opcw.nl/
Although this sites primary focus is the Chemical
Weapons Treaty, there is an excellent section, Factfinding Files, that gives accurate and even illustrated
information on chemical and biological weapons. The
main source for this information is the FOA Briefing
Book on Chemical Weapons.

opkins Center for Civilian

iodefense Studies
http://www.hopkins-biodefense.org/
The primary value of this site is its summary of the
National Symposium on Medical and Public Health
Response to Bioterrorism held on February 16-17,
1999, in Arlington. VA. Many nationally recognized
clinicians, both military and civilian, spoke at this conference along with many top government officials. The
site contains the audio (you will need RealPlayerG2 on
your computer to hear it) and PowerPoint slides from the
conference. There are very brief written summaries of
the presentations with the official publication of the
conference proceeding appearing in the CDC publication
Emerging Infectious Diseases Vol. 5 , No. 4, the JulyAugust issue (see http://www .cdc.gov/ncidod/eid/).

er and Chem~ca~
and
iol
se Command
http://www. sbccom.army.mil/
Home page for the U.S. Armys Soldier and Chemical and
Biological Defense Command. Best resource for description of military devices and products used in the detection
and defense of a WMD release. Also has a description of
the Domestic Preparedness training programs currently
being administered by the Dept. of Defense.
isease s u ~ v e ~ l ~ a n c e
http://www .who.int/emc/index.html
The primary value of this site is its monographs on various
tropical diseases that could be potentially used as biological agents of terrorism. The monographs are relatively
short but complete. There are also brief reports of outreaks
of infectious diseases in various parts of the world.

1. Scherz, R.B.; Robertson. W.O. The history of poison

control centers in the United States. Clin. Toxicol. 1978, 12

(3), 291-296.

778

Poison In~ormationPharmacy Practice

2.

8. Hanison. D.L.; Draugalis, J.R.; Slack, M.K.; Langley, P.C.

Cost-effectiveness of regional poison control centers. Arch.
Intern. Med. 1996, 156, 2601- 2608.
9. Van Buren, J.; Fishcr, L.L. Monroe County Poison
Prevention I3emonstration Project: Final Report to U.S.
Consumer Product Sufety Commission; New York State
Department of Health: Albany, New York, 1990.
10. Leikin, J.B.; Krenzelok, E.P. Poison Centers. Clinicul
Toxicology, 1st Ed.: WB Saunders Company: Philadelphia,
2000; 11 1 - 114.
11. Krenzelok, E.P. Poison centers at the millennium and
beyond. J. Toxicol., Clin. Toxicol. 2000, 38 (2), 169 170.
12. Krenzelok. E.P.; Vale, J.A. Position statements: Gut
decontamination. J. Toxicol., Clin. Toxicol. 1997, 35 (7),
695- 697.
13. American Academy of Clinical Toxicology, European
Association of Poisons Centres and Clinical Toxicologists
Position statements on gut decontamination. J. Toxicol.,
Clin. Toxicol. 1997, 35 (7), 699 -762.
14. Personal communication with the AAPCC, September 26,
2000.

Botticelli, J.T.; Pierpaoli, P.G. Louis Gdalman, pioneer in

hospital pharmacy poison information services. Am. J.
Hosp. Pharm. 1992, 49, 1445 1450.
3. Robertson, W.O. National organizations and agencies in
poison control programs: A commentary. Clin. Toxicol.
Youniss, J.; Litovitz, T.; Villaneuva, P. Characterization of
U.S. poison centers: A 1998 survey conducted by the
American Association of Poison Control Centers. Vet.
Hum. Toxicol. 2000, 42 (l), 43 53.
5 . Litovitz, T.L.; Klein-Schwartz, W.; White, S.; Cobaugh,
D.J.; Youniss, J.; Drab, A,; Benson, B. 1999 Annual report
of the American Association of Poison Control Centers
Toxic Exposures Surveillance System. Am. J. Emerg. Med.
2000, 18 ( 5 ) , 517-574.
6. Krenzelok, E.P. Do poison centers save money? What are
the data? J. Toxicol., Clin. Toxicol. 2000,36 (6), 545 547.
7. Miller, T.R.; Lestina, D.C. Costs of poisoning in the
United States and savings from poison control centers. A
benefit-cost analysis. Ann. Emerg. Med. 1997, 29, 239245.
4.

PHARiMACY PRACTICE ISSUES

Sociedad EspaAola de Farmacia Hospitalaria, La Coruca, Spain

Sociedad spanlola de Farmacia Hospitalaria, Madrid, Spain

I
Clinical pharmacy practice in Spain is very closely linked
to the concept of pharmaceutical care, as defined by Hepler and Strand:] Pharmaceutical care is the responsible
provision of drug therapy for the purpose of achieving
definite outcomes which improve a patients quality of
life. So much so, in fact, that the term pharmaceutical
care already implies the concept of clinical pharmacy. The
evolution toward pharmaceutical care implies the step in
which the pharmacist selects the therapy, taking responsibility for it, instead of only suggesting it to the
Originally introduced in hospital pharmaceutical practice, and although lack of human staff has prevented
its consolidation at all hospitals, clinical pharmacy has
grown throughout Spain in recent years. Pharmaceutical
care, introduced more recently, is the current trend in
hospital pharmacy, and is being increasingly adopted in
community pharmacy practice.
Indeed, clinical pharmacy has become so important
to pharmacy as a whole that it has now been included
as an obligatory subject in pharmaceutical teaching and
courses. Under the new educational plan, the second
cycle of the pharmacy licenciatura (roughly equivalent
to an honors degree) includes a central subject entitled
pharmacology and clinical pharmacy. [41 In 1984, a
new European Community Directive (EC Directive 84/
432) established that pharmacy undergraduate curricula
should contain a 6-month stage in a community or hospital pharmacy. In the last year, the training period for
hospital pharmacists has been increased by a year to a
total of 4 years, an extra year dedicated exclusively to
in-house clinical pharmacy training (the pharmacist visits the patients with the physician at the ward).[5
The functions of the clinical pharmacist and the
documents governing such activities in Spain are listed below.
Encylopedin of Clinical P h a m n c y
DOI: 10.1081E-ECP 120006368
Copyright 0 2003 by Marcel Dekker, Inc. All rights reserved

LL
There are a few documents that include nearly all functions developed by clinical pharmacists in Spain (see
Table 1). They are, in chronological order, as follows.

aws
Orden por la que se regulan 10s Servicios Farmaceuticos
de hospitales (Ministerio de Sanidad y Consumo,
1977).[61This is the law that primarily regulated hospital
pharmacy services, defining for the first time some of the
clinical activities that the pharmacist must develop, such
as drug information, clinical trials, or pharmacovigilance.
Ley General de Saizidad (Ministerio de Sanidad y
Consumo, 1986).17] This is a general law that regulates
most subjects health-related, including all health service
structures and requirements for drug commercialization,
as well as some of the pharmacists functions as a
healthcare provider.
Ley del Medicainento (Ministerio de Sanidad y
Consumo, 1990).[] In force since 1990, it represents
the most important law in the drugs area. It regulates
most clinical activities developed by pharmacists at any
health institutions.

oliey

ents

Coloquios de aproximacidn a la farmacia clinica

(Asociacih Espaiiola de FarmacCuticos de Hospitales,
1981).[91This document collects the conclusions of eight
debates about clinical pharmacy in which participated 200
hospital pharmacists, including subjects such as drug
selection, drug information, and pharmacist integration in
779

780

Policy Documents and Laws That Guide Clinical Pharmacy Practice in Spain

Table 1 Clinical content in general laws and policy documents that guide clinical pharmacy in Spain
Title, publication
Type of
~ o c u ~ e n t year, reference
Laws

Policy
documents

Orden 1 febrero,
1977[61
Ley General de
Sanidad, 198d7]
Ley del Medicamento,
1990[81
Farmacia Hospitalaria,
1990, 199201
Manual del Residente.
1999
SEFH Practice
Guidelines and
Consensus
Statements[13,1j

Drug
selection

Drug
information

Pharmacokinetics

Artificial
nutrition

Clinical
trials

use

vigilance

Other

No

Yes

No

N O

Yes

No

Yes

No

NO

No

No

NO

Yes

No

Yes

No

Yes

Yes

Yes

NO

Yes

Yes

Yes

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

No

No

Yes

1 7 ~ 301
9

the healthcare team. The impact of this document reached

Europe through the Eighth European Symposium on
Clinical Pharmacy, held in Lyon, France. in 1979.
Farmacia hospitalaria (Sociedad Espaiiola de Farmacia Hospitalaria. 1990).01 Edited in 1990, this book
compiles all activities, clinical and nonclinical, developed by an hospital pharmacist. Due to the success of
the first edition, two years later, the contents were reviewed, and a second edition was published, including
more details about clinical contribution of the pharmacist
on patients pharmacotherapy.
Acreditacidn docente de sewicios de farmacia hospitalaria (Sociedad Espafiola de Farmacia Hospitalaria,
1991).[l Elaborated by the National Speciality Commission, this document contains the acreditation requirements
for a hospital pharmacy service to be able to train future
specialists, as well as the program of hospital pharmacy
specialization. In 2000, the program was revised to include one more year dedicated exclusively to clinical
pharmacy training.[51
Manual del residente de farmacia hospitalaria (Sociedad Espaiiola de Farmacia Hospitalaria, 1999).[l2I Elaborated to by a consult handbook for future specialists, all
teaching hospitals participated in its creation; it contains
most activities developed by the hospital pharmacist, with
theory and practical cases.

SEFH consensus statements, practice recomnzendations, and guidelines (Sociedad Espafiola de Farmacia
Hospitalaria). As any society, the Spanish Society of
Hospital Pharmacy (SEFH) periodically publishes prac-

tice recommendations to facilitate its members work and

daily practice at hospital. They include some clinical
areas such as pharmacokinetics, artificial nutrition, and
drug information (see below).

electio

Law: Ley General de Sanidad. Ministerio de Sanidad y

Consumo, 1986.l
5.5. All people who work at health services
must collaborate in drug evaluation and control.. . .
Law: Ley del Medicamento. Ministerio de Sanidad y
Consumo, 1990.[81
Art. $4.4. and 84.6. Public Administration will
proceed for primary and specialized care structures to
make a scientific drug selection and evaluation, through
Drug and Therapeutics Committee . . . and . . . will
promote the publication of drug formularies for healthcare
professionals use.
Art. 91.2. Hospital pharmacy services will take part
in hospital commissions to participate in drug selection
and evaluation according to evidence, and drug use.
olicy d ~ ~ ~ SEFH
~ e nRecommendations:
t ~
Drug
forniular3; edition. Sociedad Espafiola de Farmacia Hospitalaria, 1994.[l3I
Through this document, the SEFH defines the concept
of drug formulary and tries to give a guide in how to

Policy Documents and Laws That Guide Clinical Pharmacy Practice in Spain

elaborate it. It must contain the drugs selected by the

Drugs and Therapeutics Committee with their basic information, institutional proceedings regarding drug prescription, and practical drug information such as drugs in
pregnancy and lactation, dose adjustment in renal or hepatic impairment, drug interactions, and so on.
Further information provided by the SEFH about drug
selection in hospitals is compiled in Chapter 2.1 of the
book Farmacia H ~ s p i t a l a r i a . [ ~ ]

Law: Ley del Medicamento. Ministerio de Sanidad y

Consumo, 1990.[s1
In primaiy healthcare
Art. 87. Functions that guarantee the rational use of
drugs: drug information to health-care professionals; drug
information to patients, drug monitoring and pharmacovigilance; promotion and participation in educating the
general public about drugs, their rational use and the
prevention of abuse.. . .
In hospital and specialized care
Art. 91.2. To achieve the rational use of drugs, the
hospital pharmacy services shall: establish a drug information service for all hospital staff, organize educational
activities dealing with issues in their field addressed to
healtcare staff at the hospital and their patients.. . .

Policy document: Procedural regulations regarding

drug information. Sociedad Espaiiola de Farmacia
Hospitalaria, 1996.[15]
This is a guide with recommendations on how best to
perform the basic duties at a Drug Information Center
(CIM). Individual CIMs adapt the recommendations in
line with their specific features. CIM directors should be
qualified pharmacists.
According to the SEFH, one of the basic functions of a
CIM is to evaluate and transmit information concerning
drugs. The following recommendations are considered
particularly important:
A regular information procedure should be established
on new developments in pharmacotherapy for the
pharmacy service staff and technical advice for the
dispensation unit concerning any medication-related
problems detected.
a
Priority should be given to aspects such as efficiency,
safety, and cost when technical reports to drug-selection committees are being prepared.
* Active information will be education- and trainingoriented and will be addressed to healthcare staff via
bulletins and to patients.

781

Passive information in response to enquiries will be as

objective, concise, useful, and clear as possible.

More complete details about a hospital pharmacists

activities concerning information on drugs and the functions of the CIM are given in Chapter 2.4 of the book
Farmacia Hospitalaria (Hospital Pharmacy) by the
SEFH.~]

Clinical P ~ a r m a c Q k i n ~ t ~ c s
Law: Ley del Medicamento (Ministerio de Sanidad y
Consumo, 1990).[81
Art. 91.2. To achieve rational use of drugs, hospital
pharmacy services shall carry out clinical pharmacokinetic activities.. . .

Policy document: SEFH recomnzendatiorzs on inical

pharmacokinetics (Sociedad Espaiiola de Farmacia Hospitalaria, 1997).[17]
The SEFH recommends that a hospitals clinical
pharmacokinetic unit should form part of the pharmacy
service and be directed by a pharmacist specializing in
hospital pharmacy. It defines the functions of this unit as
the following:
Drug selection to be included in the pharmacokinetic monitoring program, on the basis of narrow
therapeutic margin and extensive pharmacokinetic
variability.
Selection of patients to benefit from this program.
Selection of analytical methods on the basis of specificity and sensitivity.
Interpretation of plasma levels depending on the characteristics of the drug, the patients clinical data, and
concomitant treatment.
In cases where dosage needs to be modified, the
pharmacist informs the doctor in charge of the new
dosage, when it should be started. if any doses should
be avoided, the expected plasmatic levels, and subsequent analytical controls, if necessary.
Chapter 3.2 of Farmacia Hospitalaria (Hospital Pharmacy) contains a more detailed description of these activities.]

rtificiai Nutrition
Policy document: SEFH recommendations on artificial
nutrition (Sociedad Espaiiola de Farmacia Hospitalaria,
1997). 91
The SEFH considers artificial nutrition to be multidisciplinary in range and scope and, therefore, recom-

782

Policy Documents and Laws That Guide Clinical Pharmacy Practice in Spain

mends the creation of Artificial Nutrition Commissions,

in which the pharmacy service should be always and
actively represented. The main task of these Commissions is to establish an artificial nutrition protocol
that includes:

* Records of enteric nutrition, peripheral parenteral nutrition, and central parenteral nutrition.
0
Assessment of nutritional state.
* Calculation of calorie requirements.
* Administration routes.
* Biochemical monitoring.
* Standard formulas and regulations governing individual prescriptions.
In the SEFHs view, the preparation and dispensation
of artificial nutrition is not the pharmacy services only
activity, as they can also perform prescription and clinical
monitoring. This already occurs at a number of Spanish
hospitals: the pharmacist prescribes and performs daily
checkups on patients being fed artificially.

Policy document: Nutritional therapeutics (Sociedad

Espafiola de Farmacia Hospitalaria, 1992).[201
This chapter describes the activities performed by the
pharmacist as a member of the nutritional support team,
which involve a range of tasks from indications, assessment of nutritional state, and the preparation of artificial
nutrition for adults and children to concepts on basic dietetics and mother-infant nutrition. Drug-nutrient interaction analysis is another duty.

Clinical Trials

Law: Ley del Medicamento (Ministerio de Sanidad y

Consumo, 1990).[]
Chapter 3 (Art. 59-69) is devoted entirely to clinical trials. Besides the duties of dispensation and control of clinical trial samples, the hospital pharmacists
clinical duties in this area arise from his participation
as a member of the CEIC, Spains Ethical Clinical Research Committees.
Art. 64.2. The committee shall consider the methodological, ethical and legal aspects of the proposed
protocol, and the balance of risk and benefits expected
from the test.
Art. 64.3. The CEIC shall, at the very least,
consist of an interdisciplinary team involving doctors,
hospital pharmacists, clinical pharmacologists, nursing
staff and several people unconnected with any of the
healthcare professions, one of whom, at least, shall be
a jurist.

Law: Real Decreto establishing the requirements for

performing clinical trials with drugs (Ministerio de Sanidad y Consumo, 1993).[211
Heading 3 deals with CEIC. Art. 41.2 emphasizes that
the hospital pharmacist should be a member of the CEIC,
and Art. 42 describes the duties and functions of the CEIC:
. . .to evaluate the protocol and the research team,
evaluate the written information to be given to the subjects
of the research, perform monitoring of trials.. . .
Policy document: Clinical trials (Sociedad Espafiola
de Farmacia Hospitalaria, 1992).[221
Involving the pharmacist in the clinical trials may
actually facilitate the work in some aspects, including:

* Patient monitoring and follow-up, in which the pharmacist collaborates with the researcher in the compilation of analytical parameters.
0
Registering and channeling any adverse reactions observed and trying to establish the causal relation.
0
Conveying information to the patients to help them
comply properly with the protocol.

Law: Ley del Medicamento (Ministerio de Sanidad y

Consumo, 1990).]
rt. 91.2. To ensure the rational use of drugs the
hospital pharmacy services.. . shall prepare reports on
drug use.. . and perform any duties that lead to improved
drug use and control.
Policy document: Pharmacoepidemiology and drug
use evaluation (Sociedad Espafiola de Farmacia Hospitalaria, 1992).[231
Types of drug use evaluation reports, postmarketing
pharmacovigilance trials and economic appraisal in the
context of pharmacoepidemiology are described.

Law: Ley General de Sanidad (Ministerio de Sanidad y

Consumo, 1986).[71
Art. 99. Importers, manufacturers and healthcare
professionals are obliged to inform on all adverse reactions caused by drugs and medical devices, whenever
there is a risk to the life or health of patients.
Law: Ley del Medicamento (Ministerio de Sanidad y
Consumo, 1990).[
Art. 57.1. insists on the obligation to declare unexpected or toxic effects of drugs.

783

Policy Documents and Laws That Guide Clinical Pharmacy Practice in Spain

Art. 58.3. Doctors. veterinarians, pharmacists, nurses

and other healthcare professionals shall be obliged to
collaborate in the Spanish Pharmacovigilance System.
Pharmacovigilance is one of the functions of both the
primary health care pharmacist (art. 87) and the hospital
pharmacist (art. 91.2).
The SEFH has signed a Collaboration Agreement with
the Spanish Ministry of Health and Consumer Affairs to
promote and encourage the hospital pharmacists participation in the Spanish Pharmacovigilance System, which
includes, among other things, using the yellow card
system to notify any adverse drug reactions.

Law: Circular 18/90 de la Direccidiz General de

Farmacia y Productos Sanitarios. 1990.[251
Includes several guidelines on preparing pharmacovigilance trials.

Published by the SEFH in 1992, Farnzacia Hospitalaria

covers other specific duties of the clinical pharmacist in
the health system, such as clinical toxicologyi261 and
clinical activities in hospital clinical units: infectious diseases, pediatrics, oncology, gynecology, surgery. geriatrics, clinical hematology, cardiovascular, intensive care
units, psychiatry, emergencies, e t ~ . ~ ~ ]

aw: Ley de regulacidn de sewicios de las oficinas de

farmacia (Jefatura de Estado, 1997).28
Art. 1: Enumerates the functions and duties of
pharmacists working in pharmacy offices, which include
information and follow-up of pharmacological treatment
of patients; collaboration on the control of individualized
use of drugs to detect any possible adverse reactions and
inform the relevant pharmacovigilance bodies.
Since the law came into effect, the community pharmacist has evolved from a mere pharmaceutical adviser to becoming involved in the launch of pharmaceutical care programs.
ent: Granada Consensus on drugrelated problems, 1998.[29
On the assumption that the three basic objectives of
pharmaceutical care are to identify, solve, and anticipate
medicinal drug-related problems. the Consensus of Granada established a classification of such problems based
on the application of a systematic criterion of evaluation
of the requirements of pharmacotherapy : to be indicated,
effective, and safe.

Spanish Code of Pharmaceutical Ethics (Commission on

Bioethics and Pharmaceutical Ethics, Sociedad Espaiiola
de Farmacia Hospitalaria, 1998).[301
This is a consensus document promoted and prepared
by a task force from the SEFH and accepted by other
organizations, including the Sociedad EspaAola de Farmaceuticos de Atencidn Primaria (Spanish Association of
Primary Healthcare Pharmacists), the Consejo General de
Colegios Qficiales de Farmaceuticos (General Council of
the Official Colleges of Pharmacists), and the Real Academia de Farmacia (Royal Spanish Academy of Pharmacy). This code of ethics includes the basic principles
and responsibilities of the pharmacist in his relations with
the patient, other health care professionals, and society
in general.

An increasing number of Web pages of interest to the

clinical pharmacist are appearing on the Internet, including the following in Spain:
Atenci6n Farmackutica (Pharmaceutical Care). Carlos
I11 Health Institute, National Health School, http://
www.isciii.es/unidad/Sgpcd/ens/aten
far/
paginaprincipal. htm.
Club de Atencidn Farmaceutica (Pharmaceutical Care
Club), Pharmacy Faculty, University of Granada,

http://www.ugr.es/-atencfar/welcome.htm.
Ateizcidn Farmackutica (Pharmaceutical Care), Cinfa
laboratories, http://www,atencion-farmaceutica.com/.
Unidad de Farmacia Clinica y Farinacoterapin (Clinical Pharmacy and Pharmacotherapy Unit), Pharmacy
Faculty, University of Barcelona, http://www.ub.es/
farcli/wpO.htm.
Fundacidn Pharmaceutical Care EspaAa, Barcelona,
http://www.pharmaceutical-care.org.

The following are a few journals pertaining to pharmaceutical care and clinical pharmacy:
Farmacia Hospitalaria (Farm Hosp). Sociedad Espafiola de Farmacia Hospitalaria. http://www.sefh.es/
revistas/revistas.htm.
Atencidn Farnzaceutica-European Journal of Clinical Pharmacy (Aten Farm). http://www.farmaclin.
com.

784

ocuments and I,aws That Guide Clinical Pharmacy Practice in Spain

Pharmaceutical Carr ErpuZa (Phnrm Cure Esp).

Fundaci6n Pharmaccutical Care Espafia. http:llwww.
pharmaceutical-carc.cs.

16.

17.

medicamentos. SEFH 1996; 20 (77), 15S20. http::,'www.

setli.es,'norinas~normay9.htm(accessed Oct. 2000).
Airpuru, K.; Arrirabalaga. M.J.; Cao, C . Informacidn dc
Mcdicamcntos. In Farmaciu I-lospitrrlurin, 2nd Ed.;
SEFH: Madrid, 1992; 349 369.
Iiccomendaciones de la SEFH sobre FarmacocinCtica
clinica. SEFH 1997, 21 (XO), 10 1 I.http: '!www.scfh.es/
iiormasinorinay7.htm (accessed Oct. 2000).
Calvo, M.V.; Garcia, M.J.; Lanao, J.M. FarmacocinCtica
Clinica. In Farmacia Hospitalaria, 2nd Ed.; SEFH: Madrid. 1992; 436-470.
Recomendaciones de la SEFH sobre nutricicin artificial.
SEFH 199'7, 21 (79), 7 -8. http: '~www.sefh.es,normas/
norinay8.htm (accessed Oct. 2000).
Cardona, D.; AlastruC, A.; Clopks, J.; Llorens, E.; Mass6,
J.: Mira, A,: Schinca, N. Tcrapiutica Nutricional. In
Furmaria Hospitalaria, 2nd Ed.: SEFI I: Madrid, 1992;
8 50 923.
Real Decreto 561/1993, de 16 de abril, por el quc se
eatablecen 10s requisitoa para la realizacicin de ensayos
clinicos con medicainentos. BOE no. 114, May 13, 1993.
Idoate, A.J.; Cainzos, M.D.: Tdoipe, A. Ensayos clinicos. In
Farinacia Hospitalaritr, 2nd Ed.; SEFH: Madrid, 1992;
645-691.
Altirniras, J.; Segu, J.L. Farmacoepidemiologia y Estudios
de Utilizacibn de Mcdicamcntos. In Fannucia Hospitalaria, 2nd Ed.; SEFH: Madrid. 1992; 396- 435.
Chstro, I.; Altiiniras, J.; Mas, P.; Napal. V.; Olalla, J.F.;
Pardo, C.; Rodriguez, J.M. Farmacovigilancia. In F~irmacia Hospitalaria, 2nd Ed.; SEFH: Madrid. 1992; 601
644.
Circular 18/90. de 2 I dc noviembre, de la Dircccidn Gcneral dc Farmacia y Productos Sanitarios. Ministcrio de
Sanidad y Consurno, 1990.
Garcia, E.; Agudo. M.A.; Valverde. E.; Villalba, D. Toxicologia Clinica. In Furnzuciu Hospitalarian?, 2nd Ed.;
S W H : Madrid, 1992: 471 543.
Farmacia Clinica. In Farinacia Ho.s[iifalaria, 2nd Ed.;
SEFH: Madrid. 1992.
1,ey 16/1997, de 25 de abril, de rcgulacicin de servicios dc
las oficinas de farmacia. BOE no. 100, Apr. 26, 1Y97.
Pancl de consenso ad hoe. Conscnso de Granada sobre
problemas relacionados con medicamentos. Pharm. Care
Esp. 1999, 1, 107 112.
Codigo dc Ctica farmactutica. SEFH 1998, 22 (86), 15odigoctico.htm (accessed Qct.
2000).
~

18.

1.

2.

3.
4.

5.

6.

7.
8.

9.
10.

11.

12.

13.

14.

1.5.

Heplcr, C.D.; Strand, L.M. Opportunities and responsibilities i n pharmaceutical carc. Am. J. Hosp. Pharm. 1990,47
( 3 ) , 533-543.
Foppe, J.W. Atenci6n farinackutica eii farmacia coniunitaria en Europa, retos y barreras. Pharm. Care Esp. 2000, 2,
42 ~ - 5 6 .
Martinez Sinchcz, A.M. Farm. Clin. 1998, 5, 5 19.
www.uv.es/-farmacia/P_N_Farm.htm
(accessed Oct
2000).
Programa Ojiciul de lorinacidiz en la Especializcrcidn
de I'czrmacia Hospitalaria; Sociedad Espaiiola de Farmacia Hospitalaria. http://www.se~.es/residentes/programa/
programa.htm (accessed Mar 2001).
Ordcn de 1 de febrero de 1977 por la quc se regulan 10s
servicios farmacCulicos dc hospitales. ROE no. 43, Feb 19,
1977.
Ley I4/ 1986, de 2.5 de abril, Gencrdl dc Sanidad. BOE no.
102, Apr. 29, 1986.
Ley 2.511990, dc 20 de diciembrc, del Mcdicamento. BOE
no. 306, Dcc. 22; 1990.
C0l0qrui0.~ de Aproximacidn u la Farinacia Clinica;
Asociacihn Espaiiola dc FarmacCuticos de Hospital, 198 I .
Dominguez-Gil. A,; Ronal. J. Farnzacia Hospitalaria, 1st
Ed.: SW'H: Madrid, 1990.
Acreditaridrz Docent? rle Servicios d(>Furmucia Nospitalaria; Sociedad Espafiola de Farmacia Hospitalaria; SEFH:
Madrid, 1991.
Manual del Resident<>dr Farmtrcia Hospitalaria; Rermejo,
T.. Cuiia, B., Napal, V.: Valverde, E., Eds.; SEFH: Madrid,
1999.
Recomendaciones dc la SEFH: E d i c i h de formularios
oguias farmacoterapCuticas. SEFH 1994, 18 (67). 36-38.
http:)l,www.sefh.cs,'norniaslnormay5.htm(accessed
Oct. 2000).
Bonafont, X.; Pla, R. Seleccidn de Mcdicamentos. In
Farmacia fiospitulariu, 2nd Ed.; SEFH: Madrid, 1992;
269- 288.
Proyecto de recomeiidaciones dc la SEFH. Tnformacicin de

19.

20.

21.

22.

23.

24.

2s.

26.

27.

28.
29.

30.

PHARMACY PRACTICE ISSUES

Hamilton House, Virginia Beach, Virginia, U.S.A.

The United States has one of the most rigorous drug

approval processes in the world, but 51% of marketed
drugs have serious adverse effects that are not detected
during pre-marketing clinical studies."] Consequently,
post-marketing surveillance is required to collect data
about drugs or other medical products once they are
available to the general population.[21Post-marketing surveillance in the United States is the responsibility of the
Food and Drug Administration (FDA). Pharmacovigilance expands on the concept of post-marketing surveillance and is the continuous process of evaluation
accompanied by steps to improve safe use of drugs.[31
Both post-marketing surveillance and pharmacovigilance
involve pharmaceutical companies, regulatory authorities,
healthcare providers, and patients. This monograph
provides an overview of the post-marketing surveillance
process in the United States including a justification of
need; the roles of the FDA. drug manufacturers, healthcare providers, and patients; and strengths and weaknesses of the current system.

STI

EE

Pre-marketing clinical studies are only expected to detect

adverse drug events (ADEs) with an incidence of 0.1% or
greater; the ability to detect those with an incidence
between 0.1% to 1% is ~nreliable.'~]
Limitations of premarketing clinical studies include their short duration and
use of surrogate endpoints rather than clinical outcomes.
In addition, pre-marketing clinical studies are conducted
in well-defined study populations, for one indication, and
with limited concomitant medications. Finally, the number of patients exposed to the drug during pre-marketing
clinical studies is generally between 3000 and 4000. An
ADE with an incidence of 0.01%, may require a study
population of 30,000 patients to have a 95% chance of
dete~tion.~~]
The Prescription Drug User Fee Act of 1992 (PDUFA)
and the FDA Modernization Act of 1997 (FDAMA) have
Encyclopedia of Clinical Pharmacy
DOI: 10.1081/E-ECP 120006335
Copyright 0 2003 by Marcel Dekker, Inc. All rights reserved.

been credited with reducing clinical development and

regulatory review times from 30 to 12 months."' Consequently, the percent of products first available in the
United States has increa~ed.'~]
Less than one-third of new
drugs were previously first introduced in the United
States; drug events in other countries served as an ADE
early warning system. Although a decrease in review time
and an increase in first available products has raised
safety c o n ~ e r n s , ~the
~ ' frequency
~]
of labeling changes for
serious adverse events has decreased from 52% in the
1980s to 30% in the 1 9 9 0 ~ . "Furthermore,
~~
the rate of
safety-based market withdrawals of new molecular
entities has not changed; ranging from 1-3.5% over the
past several decades (Fig.

At the center of the current U.S. post-marketing surveillance process is the FDA (Fig. 2); drug manufacturers, healthcare providers, and patients are also vital to
the success of this process. Currently, only the roles of
the FDA and drug manufacturers are defined by statute.
The role of hospitals in reporting ADEs is defined by the
Joint Commission on Accreditation of Healthcare Organizations["] and of hospital pharmacists by the American Society of Health-System Pharmacists.i121For an
index of U S . federal regulations and guidelines that covers safety surveillance of drugs, the reader is referred to
an article published by Curran and Engle."31

The FDA has operated a post-marketing surveillance

program since 1961, replacing a system operated by the
American Medical Association. The FDA currently receives more than 250,000 ADE reports yearly."41 Within
the FDA, the Center for Drug Evaluation and Research
(CDER) Office of Post-marketing Drug Risk Assessment
(OPDRA) is responsible for post-marketing surveillance.
The objectives of the post-marketing surveillance program are to detect ADEs not previously observed, to
785

786

B
u

Post-Marketing Surveillance

3.0

150

gPP

5e

m
v)
w

-0

u-

a
a

1 .G

50

0 .o

0
1979-1983 (3)

1984-1988 (4)

1989-1993 ( 2 )

1994-1998* (2)

5-year approval period (number withdrawn in calendar years)

1
0
Percentage of cohort withdrawn +Number

of new molecular entities approved in calendar years

Fig. 1 New molecular entity withdrawals. NME. new molecular entity; *Prescription Drug User Free Act years. (From Ref. [6].)

improve the understanding of the potential severity of

previously anticipated risks, to detect events resulting
from drug interactions or drug effects in particular populations, and to assess the potential for causal relationships.[61 The FDAs primary mechanism for identifying serious ADEs is the spontaneous reporting system
(SRS). Additional approaches include the use of large
healthcare databases, cohort and case-control studies, and
product registries.
In 1993, the FDA introduced a new streamlined SRS,
MedWatch. MedWatch allows healthcare providers and
patients to report ADEs to the FDA by several mechanisms, including electronic and print media (Table 1).
The goals of the MedWatch program are to increase
awareness of drug- and device-induced disease, clarify
what should be reported to the FDA, simplify the reporting process, and provide regular feedback to the
healthcare community about safety issues involving medical products.]
Information received through the MedWatch program
is entered into the Adverse Event Reporting System
(AERS) database. The AERS database is designed to
permit electronic or paper submission of reports, comply
with international standards and terminology, and facilitate pharmacovigilance screening. In addition to the

MedWatch program, the FDA runs a program for adverse

events related to veterinary products and in conjunction
with the Center for Disease Control and Prevention, a
program for adverse events with vaccines, the Vaccine
Adverse Event Reports System (VAERS).
After determining that a problem exists through the
post-marketing surveillance process, the FDA has several
options. These options include medical alerts such as
Dear Health Professional letters or safety alerts published in the FDA Medical Bulletin or on the MedWatch
web site, press releases, product labeling changes, boxed
warnings, and product withdrawals. The FDA may also
require a drug manufacturer to conduct post-marketing
safety studies. It should be noted that the FDA is only able
to request that a manufacturer remove a product from
the market.

Drug manufacturers may identify ADEs through several

means, including spontaneous reports by healthcare providers or patients, clinical studies, and reviews of the
medical literature. Once the company is aware of an
ADE, the data are evaluated, the seriousness and ex-

Post-Marketing Surveillance

"Dear Healthcare Provider" Letter

Safety Alert
Press Reiease
Product Labeling Change
Boxed Warning
Product Withdrawal

I Maintain Inforvation in AERS I

Fig. 2 Post-marketing surveillance process. An ADE is serious if the outcome is death; life-threatening: requires an intervention to
prevent permanent impairment or damage; or results in hospitalization, disability. or congenital anomaly. AERS. Adverse Ebent
Reporting System. (From Ref. [16].)

pectedness are determined, and a report is submitted to

the FDA (Fig. 2). Approximately 75% of all reports
received by the FDA are either expedited or periodic
reports from drug manufacturers (Fig. 3). The process
for notification of the FDA by a drug manufacturer is
defined by the Federal Code.
The Federal Code describes two levels of ADE reporting for drug manufacturers. The first level of reporting is an expedited report for serious or unexpected
events reasonably attributed to the drug. These events
require submission of a 15-day alert report. The drug
manufacturer is also required to submit a 15-day alert
report when an increased frequency of an ADE or of drug
failure is noticed. The second level of reporting is a periodic report for all ADEs attributed to the drug. These
periodic reports are submitted quarterly for the first 3
years a drug is marketed and yearly thereafter.

Healthcare Providers
Voluntary reporting of ADEs by healthcare providers is
invaluable to the post-marketing surveillance process
(Fig. 2). These reports often provide the first signal to
the FDA that a problem exists. Whereas only serious
ADEs should be reported to the FDA, all ADEs can be
reported to the drug manufacturer. An ADE is classified as serious if the outcome is death; life-threatening; requires an intervention to prevent permanent
impairment or damage; or results in hospitalization, disability, or congenital anomaly."61 The reporting healthcare provider needs oiily suspect an association between
the drug and ADE; causality of the event does not
need to be determined. In all cases, healthcare providers need to provide complete and accurate details of
the ADE.

Post-Marketing Surveillance

788

Table 1 Contacts for adverse event reporting

Contact

Method

MedWatch
Direct mail

MedWatch
The FDA medical products
reporting program
Food and Drug Administration
5600 Fishers Lane
Rockville, MD 20852-9787
1-800-FDA-0178
https:llwww.accessdata.fda.govl
scriptslmedwatchl
I-800-FDA-7737
1-800-822-1088

Facsimile
Internet
Modem
Telephone

VAERS"
Internet

http:ll~~ww.fda,gov/cber/vaers/
vaers.htm
1-800-822-7967

Telephone
Veterinary Products
Telephone

1-888-332-8387

"VAERS = Vaccine Adverse Event Reports System

atients
The role of the patient is also vital to the post-marketing
surveillance process, particularly in identifying an ADE in
an outpatient setting. Although patients may report serious ADEs directly to the FDA or any ADE to the drug
manufacturer, it is suggested that they work through a

healthcare provider who may be able to more accurately

assess the ADE."']

The current post-marketing surveillance system involves

multiple processes and interactions. A breakdown in any
one of these processes or interactions could lead to a
weakness. Several weaknesses of the current system have
been identified. The first is the identification of an ADE.
Identification of an ADE is subjective and imprecise.['*]
A study to evaluate how accurately ADEs are identified,
found less than a 50% agreement between clinical pharmacologists and treating physician^."^] A second weakness of the current system is underreporting of ADEs. The
FDA estimates that only 1- 10% of ADEs are reported.[*']
A third weakness is the introduction of bias. ADEs reported through the SRS are not subjected to the same
rigorous standards as those determined through controlled
clinical studies. These reports are therefore subjected to a
number of biases, including the length of time a product
has been marketed, reporting environment, detailing time,
and quality of data.[211A fourth weakness is the inability
to estimate population exposure to the drug. The FDA
attempts to overcome this weakness by forming cooperative agreements with outside research organizations.
Unfortunately, these data still need to be interpreted
cautiously because drug prescribing may not equal drug
usage.[221The fifth weakness of the current system is the

300000
ii
M

2 250000

* 200000
a2

b 150000

50000
0

85 86 87 88 89 90 91 92 93 94 95 96 97 98 99
Year
Expedited 0Direct
Fig. 3 Number of periodic, expedited, and direct reports received by the FDA for the years 1985-1999. (From Ref. [14].)

~ o s t - M a r ~ e t Surveillance
in~

quality of reports submitted to the FDA. Often the poor

quality of information received does not allow the FDA to
adequately evaluate the report and be proactive in
protecting the public.'61 The final weakness of the current system is the lack of effect of the FDA's action. A
study documented that the prescribing habits of cisapride
did not change after the FDA expanded the black box
warning, issued a press release, and had the manufacturer distribute 800.000 ''Dear Health Professional"
letters."31
In spite of these limitations, the current system does
have some strengths. For example, it covers large numbers of diverse patients. Reports generated through the
SRS reflect everyday use of the drug. A second strength
of the system is the ability to monitor ADEs in an inexpensive manner. The current system is relatively inexpensive compared with an observational event monitoring
system.'241 The last strength of the current system is its
ability to generate hypotheses and signals. Currently, the
FDA is in the process of determining what constitutes a
signal: this strength is only beginning to be fully used.

The future direction of the FDA's post-marketing surveillance process is to strengthen and expand the current
system. To increase the ability to identify ADEs, the FDA
is piloting a "sentinel" system that uses a small subset of
healthcare institutions and charges them with preparing
frequent, detailed ADE reports. To increase the number of
reported ADEs, the FDA is increasing its education programs. Improvement in physician knowledge of ADEs
was reported after a 2-year program of sustained physician education. This was accompanied by a 17% increase
in the number of ADE reports ~ u b m i t t e d . ' ~To
~ ' more
rapidly investigate potentially serious ADEs, the FDA is
evaluating a plan that would increase their access to usage
and event data through large healthcare databases.
In addition to those items previously mentioned, the
FDA is also participating in the development and use of
international standards to facilitate pharmaceutical development. The goals of the International Conference on
Harmonization of Technical Requirement for Registration of Pharmaceuticals for Human Use (ICH) is to
facilitate the mutual acceptance of data submitted in
support of drug marketing applications by the European
Union, Japan, and the United States. The ICH has
developed a number of guidelines and standards to
harmonize post-marketing surveillance efforts on an
international level.[261

789

In addition to those items developed by the FDA, the

creation of an independent center for assessing pharmaceutical effectiveness has been proposed."3273281
This
center would be an independent agency that would assist
in developing answers to issues that face healthcare providers and patients after a drug has been marketed, including therapeutic differences and safety issues.

The current post-marketing surveillance system in the

United States is a multifaceted, international process involving the FDA, drug manufacturers, healthcare providers, and patients. Whereas the FDA is strengthening
the current system, its success will still rely heavily on the
submission of spontaneous reports. Therefore, healthcare
providers need to be continually reminded of the value of
reporting ADEs.

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drug safety [see comments]. JAMA, J. Am. Med. Assoc.
1998. 279 (19): 1571-1573.
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Reporting [Continuing Educarion Article]; October
1996, Available at: http://www.fda.gov/medwatch/articles/
medcont/medcont.htm. Accessed February, 2001.
3. Waller. P.C. Pharmacovigilance: Towards the next millennium. Br. J. Clin. Pharmacol. 199
4. Bess, A.L. A successful global drug safety system: The
Hoffmann-La Roche experience. Drug Inf. J. 1999, 33,
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5 . Buyse, M.; Poplavsky, J.L. Clinical evaluation of virus
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6. Task Force on Risk Management. Managing the Risks
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FDAsurvey/FDAsurvey.htm. Accessed 2/6, 200 1.
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Tufts Center for the Study o f Drug Development. User
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Curran, C.F.; Engle, C. An index of United States Federal
Regulations and Guidelines which cover safety surveillance of drugs. Drug Inf. J. 1997. 31. 833-841.
and QA/QC S o f i d y Bvuluation lnitiatives in OPDRA /Slide Pre.smtution]; 07/03/00, Available at: http://www.fda.gov/cder/prescnt/dia-62000/opdra/ 24.
sld040,htin. Accessed 2/22, 2001.
US Food and Drug Administration. MedWatch, The FDA
25.
M ~ d i c a Products
l
1icJporting Program; Available at: http://
www.fda.gov/medwatch/what.htm. Accessed 2/22, 200 I .
US Food and Drug Administration. The FDA k s k Guide
,for Adverse Event and Prodiic,t Proh1c.m Reporting;
Available at: http://www.fda.gov/rnedw~~tch/rep(~rt/desk/
26.
tpcfiiial.htm#toc. Accessed 2/22. 200 1.
Henltel, J. M(dWuic1z: FDAs Heud.s 1Jp on Medical
Product Sofety; Available at: http://www.Sda.gov/Sdac/
27.
features/1C)OX/69X-med.html. Acccsscd 02/26, 2001.
Koch-Weser, J.: Sellers, E.M.; Zacest, R. The ambiguity o f
adverse drug reactions. Eur. J . Clin. Pharmacol. 1977, 11
28.
(2), 75-78.
Kareh, F.E.; Smith, C.L.; Kerzner, B.; Mazzullo, J.M.;
Weintraub, M.; Lasagna, L. Adverse drug rcactions-a

matter of opinion. Clin. Pharmacol. Ther. 1976, 19 ( 5 Pt. I),

489 492.
Major Management Challenges and Program Risks. In
United Slate.r General Accounting Ofizcc~;January, 200 I ,
Available at: http://frwebgate.access.gpo.gov/cgi-bin/
useftp.cgi!IPaddrcss=162.140.64.2 1&fileiiame=dO 1247.
pd~&dircctory=/diskb/wais/data/gao.Accessed 2/23, 200 I .
Sachs, R.M.; Bortnichak. E.A. An evaluation of spontaneous adverse drug reaction monitoring systems. Am. J.
Scrradell, J.; Bjornson, I1.C.; Hartmna, A.G. Drug
utiliLation study methodologies: National and international
perspectives. Drug Intell. Clin. Pharm. 1987, 21 (12),
994 1001.
Smalley, W.; Shatin, D.; Wysowski, 11.K.; Gurwitz, J.;
Andrdde, S.E.: Goodman, M.; Chan, K.A.; Platt, I<.;
Schech. S.D.; Ray, W.A. Coiitraindicatcd use of cisapride:
Impact of food and drug administration regulatory action.
JAMA: .I.Am. Med. Assoc. 2000, 284 (23), 3036-3039.
Flctcher, A.P. Spontaneous adverse drug reaction reporting
vs event monitoring: A comparison. J . R. Soc. Med. 1991,
84 (6), 341L344.
Scott, H.D.; Thacher-Renshaw, A.; Rosenbaum, S.E.;
Waters, W.J.; Green, M.; Andrews, L.G.; Faich, G.A.
Physician reporting of adverse drug reactions. Results of the
Rhode Island Adverse Drug Reaction Reporting Project.
JAMA, .I.Am. Med. Assoc. 1990, 263 (13), 1785 1788.
Hamrcll, M. Current regulations and practiccs for adverse
event reporting: Implications for labeling. Drug Inf. J.
Z ~ ~ 34,
( ~97s
0 ~ 980.
Wood, A.J.; Stein, C.M.; Woosley, R. Making medicines
safer-the need for an independent drug safely board. N.
Engl. J. Med. 19998, 3 3 Y ( 2 3 , 1851-1854.
Ray, W.A.; Griffin, M.R.; Avorn, J. Evaluating drugs after
their approval Sor clinical use [see comments]. N. Engl. J.
Med. 1993, 329 (27), 2 0 2 9 ~ ~ 2 0 3 2 .

PHARMACY PRACTICE ISSUES

Les Consultants Phannaceutiques de IOutaouais,

Cantley, Quebec, Canada

I
Prescriptions foy Health, commonly referred to as the
Lowy report after its chairman, was initiated by a provincial government after noting astronomical rises in its
health care expenses on prescription drugs (20% annually
and 500% over the past decade). The report contains 147
recommendations, many directed at government, but
many also directed at the health professions, the health
science centers, the pharmaceutical manufacturers, distributors, and the public. The report was produced by a
committee appointed by the Ontario Ministry of Health.
Its members were F. Lowy (Chair), M. Gordon, R. Moulton, R. Spunt, J. Thiessen, D. Webster, and W. Wensley.
(Members Thiessen and Wensley are pharmacists.)

The committee found that Ontarians receive excellent

treatment involving prescription drugs and that they
were safe, available, and affordable through insurance
plans and government-supported programs for the aged
and those receiving social welfare. However, the committee went on to note some problem areas:
Some products paid for by the government plan were
suboptimally effective or had unfavorable benefit/
risk ratios.
Physicians are not well prepared educationally for
prescribing the many agents available, especially for
the elderly; CE programs were found lacking.
Pharmacists were not meeting their full professional
potential as members of the health care team.
Some citizens do not have access to these drugs, because they are the working poor without insurance
or have extraordinary drug costs because of catastrophic illness.
The committee found less than adequate cooperation
between the federal government (responsible for approving new drugs on the market) and provincial governments
Encyclopedia of Clinical Pharmacy
DOI: 10.1081/E-ECP 120006270
Copyright 0 2003 by Marcel Dekker, Inc. All rights reserved.

(responsible for managing drug programs for seniors and

those on social assistance).
Recommendations are directed at government, medicine, hospitals, nursing, and the public; the following is a
synopsis of those recommendations involving pharmacy:

4.22: The continuation of drug interchangeability

whereby pharmacists provide the generic equivalent (defined) of the lowest-cost product acceptable to government. This is followed by a number of other recommendations regarding drug pricing and the development
of the concept of best available price.
: That unit-dose/IV admixture be the system of
choice for institutional drug delivery in hospitals and that
the Ministry aid hospitals in the costs of conversion.

7.4: That physicians and pharmacists jointly study the

appropriateness of the quantity of drugs on a prescription
and prepare guidelines.
7.7: That postmarketing surveillance studies be established involving large numbers of family physicians
and others.
7.9: That Choice of Medications-1990 be made
available to all physicians and pharmacies and that it contain guidelines and objective information on drug prescribing.
7.11 and 7.12: That the hospital formulary system be
fostered and that the concept be extended to group clinics,
nursing and old age homes, health maintenance organizations, and comprehensive health organizations.
7:13: That generic names be on all prescription labels.
7.15: That a pilot project be established to test the
Harvard model of academic detailing.
7.18: That physicians and pharmacists establish formal mechanisms on the issues of patient counseling
and communication.
8.1: That the role of pharmacy assistants be defined
and ensure that they perform product-oriented tasks while
791

792

pharmacists concentrate on patient-oriented tasks such as

monitoring drug therapy and providing advice to patients
and other health professionals.

8.2: That information management systems be established to ensure optimal access to patient profiles and
adverse drug interaction programs.
8.3 and 8.4: That standards for original packaging
dispensing be developed.
.5: That auxiliary labels and other printed information
on prescription drugs along with verbal be increased, with
reinforcement by the pharmacist.

.6: That pharmacists pay particular attention to the

visually handicapped when labeling.

.7: That pharmacists label in the language of the

patient, with verbal reinforcement.
: That a campaign be aimed at seniors to pick one
pharmacy for all services.

.9: That patient profiles be required in all community pharmacies.

: That portable patient medication records such as
the smart card be developed.

8.11: That guidelines be developed to ensure the

pharmacist has access to the patients diagnosis(es).
8.12: That a campaign be launched to make the public
more aware of the services to be expected of a pharmacist, especially those related to the provision of information on proper use.
8.13: That all pharmacies have a private and comfortable consultation area.
8.14 and 8.15: That pharmacists exert more control
over the sale of nonprescription drugs.
8.16: That pilot projects be established to assess alternative reimbursement for the provision of pharmaceutical
services not based on the sale of a drug.
.17: That linkages involving the patient be deved between the medication profile in hospital and in
the community.
: That the clinical role of pharmacists be encouraged and expanded in monitoring and intervention
as necessary.

8.19: That pilot projects of community drug therapy

committees be established, modeled on institutional
settings.

2 0 : That drug information programs be supported

and expanded.
2 2 : That a second faculty of pharmacy, with a fivecurriculum, be established.
2 2 : That the present faculty of pharmacy (U.
Toronto) increase its curriculum to five years with more
instruction on patient counseling, therapeutics, drug information, pathophysiology, and geriatrics.
2 4 : That the practical training period be restructured.
8.25: That a PharmD program be established in two
years.
8.26: That joint teaching occur in medicine and pharmacy on patient-oriented services, including therapeutics,
monitoring techniques, and patient counseling.
: That pharmacy services to long-term institutions
be improved.

8.31: That pharmacy and nursing work out their roles

in counseling.
3 6 : That mechanisms be put in place to ensure
appropriate patient education regarding treatment plans
prior to discharge.
8.37: That all hospital pharmacies require patient
profiles.
.39: That mechanisms be established to compensate
itals providing pharmacy services to outpatients.
8.41: That funding be increased for hospital pharmacy residencies.
42: That standards and ethically appropriate mes of cost containment be established for investigational drugs.
8.45: That community programs for patient compliance be funded.
.3: That drug utilization review programs be integrated into medical CE.
9.4: That the provincial adverse drug reaction program
be supported.
9.6: That approaches be researched to reduce use of
hypnotics, sedatives, and tranquilizers.
11.1: That liquid formulations be provided to the
elderly with swallowing difficulties.
11.2: That smart cards be introduced to facilitate
monitoring and that pharmacy computer systems be
programmed to handle problems of the elderly.

793

11.5: That guidclincs be developed to limit hypnotics,

sedatives, and tranquilizers for the shortest possible time
with no repeats.

Elevcn years later, many of the recornmendations have

been carried out, at least partially. Others have not moved
significantly sincc the reports publication. Probably the
most important aspect of the report was the laundering
of thc provinces medication system in public, with responsibilities being levied at our government, our m i versities, and our professions. Yet, although the highlights of this report may have hit thc lay press for a day
or two, particularly the aspects of drug pricing, thcre is
little long-term cffcct. The provincial pharmacy associations have taken the report seriously and have initiated
many of its recornmcndations.
Thc initial concern of the government and the committee, namely, a rapidly climbing total drug bill, has
only been partially addressed. Efforts have been made to
control drugs such as omcpraLolc through the limited
use requirement, which places additional (unpaid) work
on pharmacists. Significant efforts have also been made
in some pilot prqjccts on antibiotic prcscribing: thc model
involves joint educational efforts for community physicians and pharmacists and joint eIforts to follow guidelines on a variety of infectious diseases. In areas where
thcse efforts havc been started, antibiotic costs have
fallen by 10-20%. However, overall in the province, the
drug budget continues to gallop ahead at the rate of 12%
per year.

Thc report is as relevant today as it was a decade ago.

It recognized the valuable work of clinical pharmacists
in institutions and recommended that it be extended not
only in institutions but into thc community as well. The
devclopment of the PharmD programs at the University
of Toronto (in Ontario) and thc University of British
Columbia (farthcst western province) has provided furthcr stimulus to this effort. Standards (hospital accreditation, hospital pharmacy, and community pharmacy)
also seem to have been influenced or minimally have
paralleled the recommendations of this report.
Because Ontario is Canadas most populated province,
events that occur there are often considered by othcr
provinces or in national efforts. It is therefore fair to
suggest that thc Lowy report probably had significant
influence beyond thc boundaries of Ontario.

All in all, we would do well do rcvijit these iecominendations, particularly tho\e dealing with sedmlc<\ Lare and
computerized record\. The patient orientation urged by
Lowy for pharmacists has certainly spurred the clinical
movement in this part of the world

Prescriptions for Health/Reeommanclations pour la sant6. Report

of the Pharmaceutical Tnquiry/Rapport du ComitC enyuctc de
IOntario sur les produits pharmaceutiques. Government of
Ontario, I u l y 1990.

PROFESSIONAL DEVELOPMENT

Carmen Permanyer Munn6

Pharmaceutical Association o f Catalonia, Barcelona, Spain
Benet Fit6 Novellas
Pharmacist, Barcelona, Spain

Rafael Cuayta Escolies

General Directorate of Public Health, Autonomous Govern o f Catalonia,
Catalonia, Spain

In the health sciences field, preventive medicine has

traditionally been defined as the ensemble of actions and
advice aimed specifically at preventing diseases"41 and
promoting health, and the process for enabling individuals
and communities to increase their control over the determining factors involved in health to improve it.[51
Besides health-restoring activities, there are also those
that are fundamentally preventive such as immunization,
health education for healthy people, and screenings.
As H ~ g a r t h [ pointed
~]
out, over the last few years the
meaning of the term preventive medicine has expanded
considerably. It is being applied more and more to the
health activities organized for defending and promoting
the population's health at the community level. Those
who accept this broad definition of preventive medicine
equate it with health promotion. For them, preventive
medicine would comprise all the preventive activities of
the public health services that concern the individual
(vaccination of a child, case finding in a healthy adult,
health education through the conversation during the
visit, including also certain aspects of pharmaceutical
care) or collective (immunization campaigns, collective
health check-ups, population screening, mass media
health information and education campaigns, etc.). All
these actions concern the individual and are carried out
by health services, physicians, pharmacists, and quali-

794

fied nurses, on the basis of knowledge furnished by

medical science.
Today, what we understand as health protection is the
health promotion and defense actions concerning the
environment (environmental health and food hygiene) and
it is carried out by public health professionals (veterinarians, pharmacists, biologists, health engineers, etc.) on the
basis of scientific principles furnished not only by
medicine but also by other sciences (health engineering,
architecture, food hygiene and technology, etc.).[61
In short, as Last"' pointed out, the term preventive
medicine in its broadest sense implies a more personal
encounter (immunization, screening, health education)
between the individual and the medical or pharmaceutical
personnel than that entailed in health protection activities
(potabilization and fluoridation of mains water, processing of milk, sewage disposal, etc.), since in the latter case
the professionals have no contact at all with the user.

Any disease or morbid condition is the result of a dynamic process. The causative agents or risk factors present in the environment interact, after a variable period of
incubation with the host (whose greater or lesser susceptibility to the disease is conditioned to a large extent
by genetic factors) and cause the disease. Leave11 and
Clark differentiate three defined periods in the natural
history of the disease: the prepathogenic period, the pa-

Encyclopedia of Clinical Pharmacy

DQI: 10.1081E-ECP 120006386
Copyright 0 2003 by Marcel Dekker, Inc. All rights reserved.

Preventive Medicine

795

1 Integration between the disease-generating 1

"

factors: agent, environment, and host

Sufficient n sological

1 stimulus

Presymptomatic

Clinical disease stage

stage

symptoms disease
PREPATHOGENIC PERIOD

PATHOGENIC
PERIOD

HEALTH PROTECTION

HEALTH

HEALTH

PROMOTION

RECOVERY

Environmental sanitization

Immunization, advice,

food hygiene

primary chemoprophylaxis secondary

Primary care and hospital

Screening,

care curative techniques

chemoprophylaxis
PRIMARY

PREVENT~ON

SECONDARY

PREVENTION

TERTIARY

PREVENTION

Fig. 1 Natural history of disease and levels of prevention. (From Ref. (91.)

thogenic period, and the resultr9' (Fig. 1). This division is

of great interest, as we see later in the article with regard
to the levels of prevention.

The prepathogenic period is characterized by the presence

of factors that favor or determine the development of the
disease. These factors may be environmental (infectious,
physical, chemical agents, etc.) and behavioral (overconsumption of fats or carbohydrates, sedentary lifestyle,
smoking, excess consumption of alcohol, use of illegal
substances, etc.), and they affect the endogenous genetic
predispo~ition[*~'
toward developing the disease.
Some of these factors are necessary (but not sufficient)
for the onset of the disease. The clearest example is that of
the agents of infectious diseases (bacteria, viruses, etc.).
At other times, the factors are not absolutely necessary for
disease onset, as this can occur in their absence, although
their presence implies an increased likelihood of the
condition arising. Such is the case with the risk factors for
chronic diseases (high blood pressure, obesity, smoking,
hypercholesterolaemia, etc.).[241

It should be noted that the existence of a close statistical relationship between a risk factor and a disease
does not mean that all individuals with the risk factor
will necessarily develop the disease, or that the absence
of this risk factor is any guarantee that the disease will
not develop.

The pathogenic period has two stages: the presymptomatic stage and the clinical disease stage. During the
presymptomatic period, there are no symptoms or clinical signs but, as a result of the causal stimulus, the
anatomical and pathological changes responsible for the
disease (arteriosclerosis in the coronary arteries, premalignant disorders in the tissues, etc.)"ol are already
under way.
In the clinical stage, the changes in the organs and
tissues are already important enough for signs and
symptoms of the disease to appear in the patient."']
Finally, the result is the last period in the natural
history of the disease and reflects the end of the process:
death, disability, chronicity, or recovery.

796

Preventive Medicine

Secondary Level of Prevention

Application of the concept of "levels of prevention" is

possible because, as mentioned earlier, all diseases in
their natural history present more or less defined periods
during each of which it is possible to apply some form of
preventive measures.[21
Although preventive medicine experts do not fully
agree on the limits required between each of the levels
that can be established, their differences are more semantic than
At present, preventive activities are classified into
three levels: primary, secondary, and tertiary prevention
levels,[71as shown schematically in Fig. 1.

Primary Level of Prevention

The aim of primary prevention is to reduce the probability
of disease occurring. From the epidemiological viewpoint, it aims to lower their incidence.[71 Primary prevention measures act during the prepathogenic period of
the disease's natural history before the interaction of
the risk factors andlor agents with the host produces
the stimulus that triggers the disease.
Currently, a distinction is usually made between two
types of primary prevention activities: those for health
protection, which are applied to the environment, and
those for health promotion and disease prevention, which
are applied to people. Preventive activities. then, are
really those that affect people; that is, health promotion
and disease prevention activities carried out by health
professionals and teams in primary health care.
Health protection is oriented toward the environment and includes activities aimed at controlling the
causal factors of the disease that are present in the general environment (environmental sanitization), the
work environment (safety in the workplace), or in food
(food hygiene).
Health promotion and disease prevention are oriented
toward people. With disease prevention, the idea is to
reduce the incidence of specific diseases by means of
specific actions exercised by health professionals, generally within the framework of primary care, although
they can also be applied in other areas (schools, factories, etc.). With health promotion, the idea is that people
themselves should adopt favorable lifestyles and give up
unhealthy habits through educational intervention
(health education in schools, factories, primary care
centers, and pharmacies, and via the mass media) and
legislative measures.

Secondary prevention takes place once the diseasetriggering stimulus has occurred and acted, as the only
preventive possibility is to interrupt or delay progress of
the condition by detaining it with the appropriate, early
treatment, with the aim of curing it or preventing it from
becoming chronic and preventing the onset of sequelae
and invalidity." '-I3] From the epidemiological viewpoint,
secondary prevention aims to reduce the prevalence of the
condition or disease. The basic assumption of secondary
prevention is that early diagnosis and treatment improve
disease prognosis and management.
The increase in chronic conditions in developed
countries during the twentieth century has aroused a
great deal of interest in the early detection of disease. In
such diseases, in the majority of which primary prevention
is very difficult or impossible, the strategy of the health
services must be to aim for early detection to treat them as
soon as possible and improve the prognosis. To solve the
problem of the delay in detecting chronic diseases the application of different selection processes (screenings) has
been proposed to detect them in asymptomatic persons.

Tertiary Level of Prevention

Tertiary prevention comes into play when the pathological lesions are irreversible, the disease is well established and the chronic phase has passed, and whether or
not sequelae have appeared (somatic or mental functional
limitation).[71The proposed objective is to slow the course
of the disease and alleviate any disability when it arises.[*]
In all this process, the pharmacist has traditionally been
associated to health protection activities. More recently,
however, everyone agrees on the pharmacist's role in the
field of health promotion and disease prevention: the pharmacist should incorporate, in daily practice, screenings and
health advice for the people attended to in the pharmacy.

ROLE OF THE COMMUNITY PHARMACIST

IN HEALTH PROMOTION AND
DISEASE PREVENTION
Pharmaceutical Care
Essentially, the activity of community pharmacists-that
is, pharmacists who provide pharmaceutical care for the
community from the pharmacy-is based on the purchase,
storage, and dispensing of drugs, making up extemporaneous preparations, pharmacotherapeutic follow up of
patients, and advice about drugs and health problems."43231

Preventive Medicine

Table 1 Importance of community pharmacy in health

promotion and disease prevention
1. Community pharmacy is frequently the first contact with the
health system: high frequency of contacts with low barriers to

access (no appointments, no long waiting time, convenient

opening hours, located within communities, information
readily on display, etc.).
2. Community pharmacy reaches the broad population: they see
a wide range of potential target groups within the patients/
clientshsers (people with incidental needs, people with
chronic illness, healthy people, people from all social strata).
3. Community pharmacy contacts have a good potential to
integrate the social environment into counseling (geographic
distribution, positioning on the high street, principal shopping areas. etc.). Contacts take place often and normally on a
regular basis and include interactive, communicative, and
counseling aspects.
4. There are a large number of experts, pharmacists, and other
qualified staff working in community pharmacy, offering a
high level of competence and knowledge of medicines.
5 . Health issues are already on the agenda of the users of
community pharmacies, and the pharmacists are considered
experts in a variety of health issues and often actively provide
a link to other health professionals. mostly to general practice
doctors.
6.Community pharmacy can offer a balanced mix of contributors to curative care, prevention, rehabilitation, and
health development.
(From Ref. [23].)

Over the last few years, applying the criteria of

pharmaceutical care, pharmacists have extended their
activity to embrace other health interventions associated
with improving peoples quality of life. In 1993, within
the framework of the International Pharmacists Congress,
FIP93,15] the Declaration of Tokyo was approved. In
that declaration. pharmacists gave the definition of
pharmaceutical care and stated that the patient is the
principal beneficiary of their actions. Pharmaceutical
care is defined as the ensemble of attitudes and actions
involving medication and the role of the pharmacist as a
health agent. The main implication arising from this
viewpoint was the conviction that pharmaceutical care
must be developed as an integral part of health services.
The objective of pharmaceutical care in the community
is to participate in health promotion, disease prevention,
and education. The declaration also proposes specific
spheres of action: the rational use of drugs; smoking cessation; and advice on vaccination, hygiene, family planning, AIDS prevention, etc. Even now, pharmacists have
still not fully developed their potential as health agents
within this health system,[16]but the community pharmacy
is of specific importance for health promotion (Table I).

797

rams of ~ r e w e n ~ ~Actiw~ties
we
in ~ommunityPharmacy
In practice, health promotion from the community
pharmacy has been described in different studies published
since 1950, although more frequently since 1980 and,
specifically, in studies conducted in England and Canada.
In 1993, the Health Education Authority and the
National Pharmaceutical Association published .Health
Promotion and the Community Pharmacist ,[17] which
serves as a practical guide for all health promotion activities that can be carried out by British pharmacists from
the community pharmacy.
Along the same lines, another publication to be noted
is Pharmacies and Smoking Cessation ,[lS1which within the WHOS European program plan of action for a
tobacco-free Europe was started in 1993 in pharmacies in
Denmark. The result being that, at present, 20% of Danish
pharmacies routinely offer a smoking cessation service
for their population.
In Catalonia (Spain), in 1997, a consensus among the
Department of Healths experts in preventive medicine,
nursing, and pharmaceutical scientific associations was
attained. It was decided to initiate a process to implement[I3] different activities in the community pharmacies
in Catalonia (Table 2). These activities have been chosen
according to the health plan priorities. The most important
point is that these activities are carried out with collaboration with the health care teams of primary health
care centers. It was first implemented as a training
trainers procedure and now these activities are carried
out in most pharmacies in Catalonia since 1997.39,201
Also in Catalonia-Barcelona
to be specific-the Pla
Farmackutic dEducaci6 SanitBria[ (Pharmaceutical
Plan for Health Education), drawn up by the Barcelona
Table 2 Specific preventive activities in Catalonias
community pharmacies
1.
2.
3.
4.
5.
6.

7.
8.
9.
10.
11.
12.

Screening for high blood pressure.

Screening for excess weight and obesity.
Screening for hypercholesterolaemia.
Advice on drug use and self-medication.
Advice on active immunization.
Advice on preventing sexually transmitted diseases and
AIDS.
Advice on giving up smoking.
Dietary advice.
Advice on preventing mouth and teeth diseases.
Advice on, and prescription of, physical exercise.
Advice on excess alcohol consumption.
Advice on screening for breast cancer and cervical cancer.

(From Ref. [l].)

Preventive Medicine

798

Pharmaceutical Association, proved the viability of

health education in both the therapeutic and health promotion spheres. Three hundred pharmacists took part
in the experiment in Barcelona, the educative sessions
being attended by around 10,000 people. The evaluation
proved the value of exercise as it helped to significantly
increase the knowledge of those attending about the
matters discussed.
Also to be noted are the two health education plans
drawn up in Spain by the Consejo General de Colegios
FarmacCuticos (General Council of Pharmaceutical Associations), with the collaboration of the provincial
associations: the Plan de Educacidn Nutncional (Plan for
Education on Nutrition)[* and the Plan de Educacidn
sobre el medicamento (Plan for Education on Drugs).[221

Table 3 What can health promotion offer to the

community pharmacy?
Increase impact and effectivessnes of pharmacotherapy
Increase impact and effectivessnes of counseling and healthrelated advice
e Increase job satisfaction by job enrichment:
- By fostering liaison with users
- By improving cooperation with other providers
- By making visible the cognitive service information,
advice, and counseling
e Make the contribution of community pharmacy evident
- In the management of drug therapy
- As an important place for health-related service
a Support the integration of community pharmacy into the
primary health care team
a

(From Ref. [23].)

For the pharmacy pharmacist to be able to carry out the

health promotion and disease prevention activities with
due rigor and consistency, and for these activities to be
well coordinated in primary health care, it is necessary to
perform the following:

1. Give priority to activities that, in healthy adults,

have shown to be effective in the population; that
is, they have provided some health benefit for the
community and constitute a framework of reference that makes it clear which preventive activities should be carried out at the pharmacy.
2. Adapt the joint development of these activities to
the needs and programs established for each basic
heaith area. The idea resulting from all this is that
there has to be coordination between all the agencies and professionals involved in primary health
care, and the appropriate supports and mechanisms
for achieving this coordination.

In practice, to carry out the preventive activities defined, the pharmacist will have to take into account the
need for the following:
Reinforcing knowledge, skill, and attitude through
accredited, continued training.
Creating an atmosphere and place for these
activities.
Having the necessary measuring equipment and
resources for the activities.
Setting a good example, both the pharmacist and
the other personnel, to reinforce the aforementioned healthy atmosphere.

5. Organizing, recording, and establishing protocol

for the activities to evaluate them in accordance
with the quality criteria established and divulge the
results.
6. Using the communication currents established with
the appropriate graphic supports for the purpose of
exchanging information (Appendix 1) with the
primary care team of the health areas.
Applying health promotion principles could be a
means to further develop the professional role (Table 3).

Health promotions activities in primary health care, in

general practice and in community pharmacy, is not yet
well documented or evaluated with sufficiently high
quality standards. There seems to be a wide variance in
the degree to which health-promoting services, projects,
and programs are documented, evaluated, and evidence
based. In particular, there seems to be need for further
work concerning lifestyle counseling, health education,
and interventions for health development.[231
The need to be able to evaluate the effectiveness of the
activities is obvious. Therefore, it will be essential to
specify, during the process of implementing health
promotion at the pharmacy, what the particular objectives
are and which activities must be carried out, while
ensuring that the former are attainable and the latter
feasible on the basis of the resources available. It will be
necessary to plan a careful implementation strategy that
will ensure the participation of as many professionals as
possible while also permitting evaluation of the repercussions, on the populations health, of the integration of
health promotion activities into the pharmacists practice.

Preventive Medicine

799

P ~ N D I X1

Servei Catala de
la Salut

Consell de Col-legis
Farmaceutics de Catalunya

M
pharmacy

From

primary care centre

(full name and address)

0
0

telephone number
primary care centre

To

pharmacy

(full name and address)

0
0

telephone number
Patients data
1st surname

2nd surname

name

Reason for consultation

Comments on the reason for consultation

Stamp and signature

Date:

Report from the department consulted (if necessary)

Stamp and signature

Date:

NCR paper

800

I.

2.

3.

4.

5.
6.

7.

8.

9.
10.

II.

12.

Preventive Medicine

White Paper. Integration of Prevention in the Community

Phurmucy: Catalan Health Servicc and Pharmaceutical
Association of Catalonia, 1997.
Salleras, L. Le basi scientifiche della medicina preventiva.
(The scientific principles of preventive medicine). Riv. Ital.
Salleras, I,. La medicina prc\7cntiva en la asistencia
primaria. (Preventi\#e medicine in primary care). Rev.
Sanid. Hig. Publica 1987. 61. 545-570.
Salleras, L. Salud dcl adulto. (The Adult's Hcalth). In
Medicinci Preveirtiva y Salud Piblica. (Preventive Medicine and Public, Health); PiCdrola, G.G., Dcl Key, C.J.,
Dominguez, C.M., Cortina, G.P., Gilvez, R.. Eds.; Ed.
Salvat: Barcelona, 1991: 1148-1162.
Termiizology for tlze EUI-opeciiiHealth Policy Conference;
WHO Regional Office for Europe: Copenhagen, 1994.
Salleras, S.1,. Wucacidn Sanitarici: Priizcipios, Me'todos J
Ap1icacione.r. (Health l<ducrition: Principles, Methods and
A~~~)lic~citionsi:
D i a ~de Santos. Ed.; Madrid, 1985.
Hogarth. J. G l O 5 , w i ~of H ~ a l t l iCare Tei-minology. Public
Health ii7 Europe; WHO Regional Office for Europe:
Copenhagcn. 1978.
A Dictioncity o[ Epidmziology; Last, J.M., Ed.: Oxford
University Prcss: New York, 1983.
LeaLell. H.R.; Clark. E.G. 7kxthook of Prcw'ntive M e diciizc.: McGraw Hill: New York, 1953.
Commission oiz Chronic illizess: Chronic Illness in the
United Stater. Vol. I PrcJventiorz of Chi-onic illness; Haryard Ihivcrsity Press: Cambridge, Massachusetts, 1957.
Fletcher, R.H.: Flctchcr, S.V.; Wagner, F.H. Clinical
Epidcmiology. I n The E.ssential: Williams and Wilkins:
Baltimorc, 1982.
Wilson, J.M.C.: Jungcr. 6. Principios y mCtodos del
examen colcctivo para identificar enfermedades. (Principles and Mcthods of Collective Screening for Identifying
Discases). In Cuadernos de Sahd Piblica; Organizacibn
Mundial de la Salud: Ginebra, 1969; Vol. 34.

13. AlvareL, D.C.; Bolumar, F.; Garcia, B.F. La dctecci6n

precor de enfermedades. (Early detection of diseases).
Med. Clin. (Barcelona) 1989, 93, 221-225.
14. Decision no. 645/96/CEE of thc European Parliament and
Council, of 29 March 1996, for adopting a Community
programmc for promotion, information, education and
training i n health matters within the framework of action in
the public health sphcrc (1996-2000).
15. 532 International Pharmacists' Congress, FIP'93, Tokyo.
16. The Role and Function of the Pharmacist in Europe;
STYX Publications: Groningen, 1989.
17. Health Pmmotion and the Community Pharmacist; Health
Education Authority: London, 1994.
18. I i z t e i m k ~ n a l Guide: Plzamzacies and Smoking Cessations, 1993; WHO Regional Office for Europe: Denmark,
1993.
19. Bassons, M.T.; Gascon, M.P.; Gamundi. M.C. Pla farmackutic d'educacio' smithria, Collegi de Farmackutics tie la
Provincia dr Barcelona, Abril 1995. (Plzarnzaceutical plan
[or health education; Pharmaceuticd Association qf the
Province of Barcelona, April 1995).
20. Pla de Salut de Catalunya 1996-1998. (Health Plan for
Catalonia 1996- 1998). In Generalitat de Catalunya;
Departament de Sanitat i Scguretat Social: Barcelona,
Abril 1997.
21. informe Plan de Bducacicin Nutricional por el furmcic4Litico (Pleaufar). (Report on the Plan ,for Nutritional
Education Through Pharmcici.sts): Consejo General de
Colegios Farmackuticos. 1993.
22. Guki p u i u el ,fiirmuc&utico. Texto ba.re &I prograina de
educacicirz sobre el medicamento. (Guide f o r the pharmacist. Basic text of the drug education programme);
Consejo General de Colegios Oficialcs de Farmackuticos:
Madrid, 1994.
23. Krajic, K. Hcalth Promotion in Primary Health Care:
General Practice and Community Pharmacy, A European
Project. In Opportunities, Models, Experiences; Ludwig
Boltrmann-Institute for the Sociology of Health and
Medicine, April 2001,

PHARMACY PRACTICE ISSUES

American College of Clinical Pharmacy

Kansas City, Missouri, U.S.A.

Health care reform has renewed the interest in primary

care. Major problems with America's health care system
include escalating health care costs, maldistribution of
health care providers into urban areas, lack of health care
insurance, and the excessive utilization of specialists.
These issues have assured that health care reform will
take place. At the time of this report, the nature and format of a reform plan has not been determined. Nevertheless, many agencies are rapidly evaluating their current
health care coverage and are preparing for the inevitable
reform that will take place.
There have been disproportionately high numbers of
medical specialists compared with generalists since the
1960s."l Worldwide, there are approximately five to six
generalists for every subspecialist. For various reasons,
perhaps most importantly, economics, this ratio is reversed
in the American health care system. For well over 20
years, governmental agencies and medical academicians
have tried to increase the numbers of primary care providers without significant success. With millions of
underinsured Americans, the provision of primary care
has become a national priority. Clinical pharmacists must
become more involved in the provision of primary patient
care. Most clinical pharmacists, however, have not viewed
themselves as primary care providers and, therefore, may
not feel adequately prepared to become a member of an
interdisciplinary primary care team.
This article is an extension of a previous American
College of Clinical Pharmacy (ACCP) White Paper on
Clinical Pharmacy Practice in the Noninstitutional SettingL21That white paper described the functions that
should be expected of clinical pharmacists in ambulatory
care settings. This article assists practitioners and administrators who want to establish and evaluate services in
ambulatory care and primary care settings. This article

From Pharmacotherapy 1994, 14(6):743-758, with permission of the

American College of Clinical Pharmacy.
Copyright
1994 by the American College of Clinical Pharmacy.
Encyclopedia of Clinical Pharmacy
DOI: 10.1081/E-ECP 12000641 1
Published 2003 by Marcel Dekker, Inc. All rights reserved

presents approaches to define the scope of a pharmacist's

practice and obtain clinical privileges, evaluate the process
of delivering care, evaluate patient outcomes related to
pharmacotherapeutic decisions, and define the legal
implications of providing primary patient care.

There is considerable confusion in pharmacy concerning

current definitions of practice sites and practice philosophies. Ambulatory care includes all health-related
services in which patients walk to seek their care."] These
services may be provided in emergency rooms, urgent
centers, private offices, primary care clinics, specialty and
subspecialty clinics, and community pharmacies.
Primary care is a subset of ambulatory care with unique
features and philosophies."' (By definition, inpatient care
is never a primary level of care.) One set of definition^,[^'
suggests that primary care is a form of care that includes:

1. "First-contact'' care, serving as a point-of-entry

for the patient into the health care system;
2. Continuity by virtue of caring for patients over a
period of time, both in sickness and in health;
3. Comprehensive care, drawing from all the traditional major disciplines (medical specialties,
nutrition, and social) for its functional content;
4. The assumption of continuing responsibility for
individual patient follow-up and community health
problems; and
5. Highly personalized care.
Dr. Elizabeth Short of the Veterans Administration
(VA) Central Office has stated, "Primary care is the
coordinated, interdisciplinary provision of health care that
consists of health promotion, disease prevention, comprehensive management of acute and chronic medical and
mental health conditions, and patient education. A primary
care physician coordinates access to and integration of
other components of health care, such as inpatient, longterm, or subspecialty care, and psychosocial support. Un801

802

der primary care, a provider or provider team is the primary source of a patients care, and the place that a patient
turns to for health care information and support.[41
The key feature of primary care clinicians is that they
handle a wide range of medical conditions. They serve as
the entry point into the health care system and decide on
referral or triage to secondary or tertiary levels of care.
Specialty clinics provide ambulatory care, and, in many
cases, some primary care. Most specialists (e.g., cardiology, neurology, nephrology, etc.), however, are considered secondary levels of care. These secondary and tertiary
levels of care should be utilized when a problem is beyond
the expertise of the primary care clinician. The typical
family practice physician or general internist cares for well
over 90% of problems that present to them. There is a
small percentage of problems that would require referral to
secondary or tertiary care. Even when a patient is referred
for a specific problem, the primary care clinician should
maintain overall care for the patient and coordinate all
other aspects of care. This continuity implies chronic care
and preventive care that are more conducive to long-term
assessments of patient outcomes than can be achieved with
acute illness managed in the inpatient setting.[31
Clinical pharmacists and pharmacotherapy specialists
provide care in a wide variety of ambulatory care and
primary care settings.*21There are two major types of
practice that are very distinct. While currently more common in structured settings such as hospitals and health
maintenance organizations, primary care is increasingly
being provided in many settings including community
pharmacies. The first type of practice is one in which the
pharmacist is independently responsible f o r providing
primary care, typically between regularly scheduled physician visits. This includes conducting complete histories;
obtaining objective information including physical assessment and ordering laboratory tests; starting, stopping, or
changing drug therapy; and determining the appropriate
timing of follow-up visits. These activities are common in
pharmacist-managed clinics in the Indian Health Service,
medical centers, and VA hospitals, including hypertension, diabetes, hyperlipidemia, anticoagulation, and pharmacy service clinics. These activities are in contrast to
those provided by other professionals such as physician
assistants or nurse practitioners who may perform functions traditionally performed by a physician.
The second type of setting is an interdisciplinaiy team
approach to care of the patient where the pharmacist sees
patients with physicians. Pharmacists who work in such
teams assist with care at the same time other health
professionals see the patient. In this setting, they may have
independent patient care activities but these would not be
as extensive as are generally seen in pharmacist-managed

Primary Care, Clinical Pharmacy Services in (ACCP)

clinics. These settings would include family practice offices, general medicine clinics, or pediatric clinics.

ESTABLISH IN^ N AMBULATORY CARE OR

PRIMARY CARE PRACTICE
Obtaining Clinical Privileges
Prior to any patient intervention, it is essential that the
clinical pharmacist has in place a document that outlines
specifically the practitioners scope of practice.[] It is
important that the scope of this document be sufficient to
allow the clinical pharmacist to function as a member of an
interdisciplinary primary care team. This document could
be in the form of clinical privileges or a scope of practice
statement (Appendix 1). This approach could be used for
developing a practice for a new practitioner or used for a
previous clinician who has not formally obtained scope of
practice privileges. If the facility is an organized health
care center (hospital or managed-care organization), it
would be worthwhile to review the facilitys guidelines for
clinical privileges granted to the physicians assistants and/
or nurse practitioners if these are available. Depending on
the institution, approval is required by the Chief of
Pharmacy, Chief of Staff, Clinical Executive Board, and
the Institutional Director. Once these privileges are established, only then can the clinical pharmacist provide
primary patient care (e.g., in pharmacist-managed clinics).
In the past, formal guidelines to obtain clinical privileges were often not commonly developed in private
practice or other settings such as outpatient family practice
settings. However, clinical pharmacists in private practice,
community pharmacies, family practice residencies, and
health maintenance organizations should develop these
guidelines for their clinical pharmacy practitioners to
ensure quality and evaluate performance. For clinicians in
these settings, it is less likely that formalized arrangements
for scope of practice privileges exist with physicians or
other health professionals. However, similar templates as
those for institutions (Appendix 1) could be used and modified for these settings.
The application form in Appendix 1 also requests data
on whether the clinical pharmacist is board certified in
pharmacotherapy or another specialty. Board certification
should be considered strongly desirable, if not required.
At the present time, the most appropriate specialty
certification process for ambulatory or primary care
pharmacists would be certification in pharmacotherapy.
This would be analogous to physician certification in the
broad-based specialty of family practice. Board certification in pharmacy will be increasingly important and it

803

Primary Care, Clinical Pharmacy Services in (ACCP)

should be achieved by all ambulatory care/primary care

pharmacy practitioners who provide the services outlined
in this report.

factors to address if patient satisfaction is being assessed.

Providing these personal services is not new but it is
increasingly important when patient satisfaction drives
third-party contracts in managed care. Pharmacists must
provide these personal levels of care if they truly are
delivering pharmaceutical care.

valuating the Process of

A comprehensive discussion of quality of care assessments is beyond the scope of this paper. This area of
assessment, however, will become increasingly important
in the near future. This report is intended to provide the
pharmacist who practices in ambulatory care with an
understanding of basic principles used to assess quality.
For more in-depth reviews in this area, the reader is
referred to the references and the Appendixes.
There is a great deal of interest in measuring or
assessing patient outcomes. As Donabedian points out,
however, outcomes can only be assessed within the
overall context of health care.61For instance. the therapy
that a pharmacist selects may have minimal influence, or
perhaps even a detrimental influence on patient care,
depending on the care of other practitioners, demographic
factors, and the interpersonal relationship. Donabedian
maintains that quality can only be assessed by examining
the three components: structure, process, and outcome.[61
He suggests that there must be a knowledge of how
structure and process are linked, and how outcome and
process are linked before quaiity assessments can be
made. Structure not only refers to the facility, its services
and its location, but also the number and characteristics of
the providers. For providers this would mean whether
they are in solo or group practice and whether they are
For physicians it has been shown that
board
board certification is a predictor of good process, but only
by implication, of good outcomes. Process refers to what
is done for the patient in providing
This includes
making diagnostic and treatment decisions. Outcome refers to what happens to the patient and this may include
the patients knowledge or satisfaction with care.
Lohr and Brook have stated that quality of care is
composed of both technical care and the art of care.[71The
art of care includes the practitioners ability to provide
reassurance, obvious concern of the patients well-being,
good counseling, and sensitivity to the patient. As
examples, they cite whether the provider introduces
himself to the patient. refers to the patient specifically
by name, announces and/or explains activities before or
while doing them (such as physical examination), and says
goodbye to the patient. Obviously, these are all critical

Performing quality assurance evaluations of specific

pharmacists performance does not measure patient outcomes, but rather, the process of delivering care. However,
providing an acceptable or ideal process (or standard of
care) should. by implication, create an environment
conducive to better patient outcomes. However, to move
from evaluating process to evaluating outcome, other
specific tools must be used (see below). Appendix 2 is an
example of a quality assurance form that might be used in
a pharmacist-managed primary care clinic.
Guidelines are being developed for a wide range of
disease states and conditions. These essentially describe
processes for delivering care. They can be used by the
individual clinician to prospectively guide appropriate
therapy. In contrast, they can be used retrospectively as a
quality assurance measure. Appendix 3 lists 12 disease
states that are critical to outpatient primary care, and that
are currently the most common conditions cared for by
pharmacists in primary care settings. While these are not
all-inclusive, they provide examples that can be followed
in other therapeutic areas. Where possible, nationally
accepted clinical practice guidelines are provided for each
of these disease states. It is imperative that clinical
pharmacy practitioners be aware of nationally accepted
guidelines for specific conditions they may treat in their
settings. The importance of this is discussed below.
The Agency for Health Care Policy and Research
(AHCPR) was created by Congress to be the successor
of the National Center for Health Services Research.
This agency explores medical conditions that affect
large populations, have multiple therapeutic interventions,
and have a large economic impact. Through the Medical Treatment Effectiveness Program (MEDTEP), the
AHCPR examines variations in health care practices on
patient outcomes.[s1 The MEDTEP involves patient outcomes research, clinical guideline development, scientific data development, and research dissemination. The
agency has supported the development of numerous
guidelines such as the guidelines for depression and for
angina.[91 The AHCPR is currently developing practice
guidelines for the effective therapeutic management of
asthma, arthritis, hypertension. and congestive heart
failure. In addition to this federal agency, private groups

804

such as the American College of Physicians, the American Medical Association, the BlueCross Blueshield
Association, and other specialty societies are developing
new treatment guidelines.
It is important to note that AHCPR is not a regulatory
agency and is not involved with reimbursement. Application of the guidelines is not enforced by the government.
Using these guidelines that were prepared by multidisciplinary panels of experts may allow primary care providers to deliver scientifically sound care to the patient.
There are also medical-legal issues pertaining to
clinical practice guidelines developed by specialty societies. The general counsels who are involved with these
issues, private practice attorneys, and the counsel of the
American Medical Association generally believe that following established clinical practice guidelines would be a
strong defense in malpractice cases. However, if a practitioner deviated widely from these guidelines, he or she
would need to have a strong rationale, documented in the
patient's record, to support the use of an alternate regimen.
A major issue that needs to be addressed is what
standards or methodologies should be followed when
guidelines are developed."01 A structured, systematic,
science-based approach should be used whenever developing these guidelines. The Institute of Medicine has
identified the necessary characteristics which would enhance a guideline's effectiveness: sensitivity, specificity,
patient responsiveness, readability, minimal intrusiveness,
feasibility, and computer compatibility." 1312' If guideline
development followed these scientific methods, it would
be difficult to criticize the process.
In contrast to good guideline development, the determination of whether guidelines are useful depends
upon their readability, computer compatibility, and other
factors. Outcomes management takes the results of the
outcomes research and incorporates them into clinical
practice guidelines to theoretically help ensure all patients
receive the most effective treatment available." 13121

Another objective of this report is to determine the best

method to measure the impact of pharmacotherapeutic
decisions made by clinical pharmacists on patient outcomes. There are several approaches that can be used to
assess outcomes. These include disease- or treatmentrelated outcomes (e.g., blood pressure, seizure frequency,
medication adherence, target serum concentrations). The
Task Force felt that it was not appropriate for this report
to delineate specific clinical outcomes such as level
of blood pressure control or serum drug concentrations.
While these are important outcome measures, the Task

Primary Care, Clinical Pharmacy Services in (ACCP)

Force wanted to highlight optimum methods for documenting positive outcomes of clinical pharmacy interventions. To keep in step with health care reform, a
good method of assessing the impact of therapy on a
specific chronic disease is health-related quality-of-life
(HRQL) outcome measures. The pharmaceutical industry, the medical profession, and governmental agencies
have shown increasing interest in assessing new measures of a drug's overall effectiveness. Quality of life
(QOL) will be considered as seriously as safety and efficacy when evaluating response to therapy.
Even when primary care providers follow accepted
clinical practice guidelines, there is no assurance of a
favorable outcome. That is why it is important for the
clinical pharmacist to understand and use appropriate,
clinically relevant outcome measures to quantify the
impact of their interventions."21 Bungay and Wagner
argue that HRQL outcome measures should assess physical, social, and role functioning; emotional distress and
well-being; general health perceptions; and energy and
f a t i g ~ e . " ~They
]
also stress that the assessment of health
status must be integrated into the care of patients. HRQL
measures can be used to assess a population with a specific
disease, or as a research method to examine how changes in
process affect outcomes."41 The current challenge is to
develop tools and operations that can be used in the office
setting to evaluate care, and hopefully direct treatment for
individual patients. It is critical, however, that these assessments be performed while considering the patient mix,
timing of data collection (timing during the evolution of a
disease process), patient characteristics, and measurement
properties. The reader is referred to a more comprehensive
discussion of these issue^."^.'^^ We will briefly discuss the
importance of HRQL outcomes, the types of instruments
available, and how to choose a specific instrument for a
specific patient population.
Quality of life includes many issues occurring in a
person's life, such as health status, job satisfaction, family
Since these are
issues, and overall
nonspecific, this measurement may not be the best indicator of positive or negative pharmacotherapeutic interventions made by a clinical pharmacist. Health-related
quality-of-life assesses those aspects of a patient's life
specifically related to physical and mental well-being.
"Hard data" such as treadmill time in patients with heart
failure may be of interest to clinicians, but is of little value
to the patients. Frequently, "hard data" correlate poorly
with the patient's actual functional status. An additional
reason to add HRQL instruments to clinical outcomes
measurements pertains to the phenomenon that patients
with the same medical condition often respond differently
to therapy. HRQL is a complementary method of meas-

805

Primary Care, Clinical Pharmacy Services in (ACCP)

uring the impact of therapy on chronic disease. Thus,

HRQL might be used in tandem with explicit or implicit
quality assurance review that is measuring the process of
delivering care along with clinical outcome measures
(e.g., blood pressure for hypertension or peak flow measures for asthma).[61
Primary care providers, patients, and health care administrators are interested in HRQL outcomes because
they are a method to measure the impact of therapy on the
disease process. Hospital administrators and other policy
makers have a high stake in these issues because payers
are beginning to use HRQL data in their reimbursement

The Health Outcomes Institute has developed and

validated several outcome instruments that can be used to
evaluate patient outcomes following interventions by
pharmacist^."^] These include hypertensiodlipids, angina,
asthma, chronic obstructive pulmonary disease, chronic
sinusitis, hip replacement, hip fracture, depression, low
back pain, osteoarthritis, alcohol abuse, stroke, rheumatoid
arthritis, and prostatism (Appendix 4). The Health Outcomes Institute is located at 2001 Killebrew Drive, Suite
122, Bloomington, MN 55425; telephone (612) 858-9188.

It is imperative that clinical pharmacists involved in

providing primary patient care have a good working knowledge of HRQL instruments and are competent in choosing
the appropriate methods to assess their interventions.
Generic instruments and disease-specific instruments are
the two general means by which HRQL can be measured.
The first modem health status questionnaires were very
long, but their results were well validated. The Sickness
Impact Profile (SIP) is an example of an early profile. It
includes a physical dimension and a psychosocial dimension."4-1'1 A dimension is a quality or aspect that is a
component of health. The SIP also includes five independent categories including sleep, rest, eating, work, and home
management, as well as recreation and pastimes. More
recently, shorter profiles have been developed such as the
Nottingham Health Profile and the Medical Outcomes
Study (MOS) 36-Item Health Survey (SF-36) (Appendix 4).
The other approach in assessing HRQL is to focus on
the aspects of health status that are specific to a particular
area of interest or disease. By narrowing the area being
observed, it is possible to gain increased responsiveness to
changes in therapeutic interventions. Responsiveness
relates to the instrument's ability to detect changes in
the patient's status over
The instrument may
be specific to a particular disease state (e.g., angina or
arthritis), or to a population (e.g., the frail elderly), or to a
physiologic problem (e.g., pain). In addition to responsiveness, these disease-specific instruments evaluate areas
routinely addressed by primary care providers.r171
Most generic and specific HRQL measures used today
have been validated, but not in all populations. If an
instrument is valid, it has been statistically determined to
measure what it is intended to measure. Compendia of
available measures, including critical reviews, can facilitate the choice of an instrument for a specific setting or
purpose."'] Appendix 4 contains some generic health
profile instruments that can be used for various disease
states, and, where possible, a disease-specific instrument
was listed.

If pharmacists were providing primary care for hypertensive patients and wanted to compare the results of an
intervention, they should first provide interventions based
upon established therapeutic guidelines for treating
hypertension such as those outlined by the Fifth Joint
National Committee on Detection, Evaluation, and
Treatment of Hypertension (JNC-V). With each patient
encounter, they would collect the data in Appendix 2.
These two procedures would ensure that the pharmacist is
providing an appropriate process of care.
Prior to the intervention, the pharmacist would assess
health outcome measures such as blood pressure, current
medication adherence, and forms such as a general form
(e.g., SF-36) and a disease-specific form (e.g., Hypertens i o d i p i d Form 5.1) (Appendix 4). After the pharmacist
intervention, a predetennined period of time must elapse
before these questionnaires can be repeated (e.g., 6- 12
mo). The questionnaires and blood pressure assessments
are then repeated and it is determined whether the
intervention had any effect on the patient outcome.

Example

Recommendations
When appropriate, generic assessment measures
should be used to develop methods to evaluate
overall patient outcomes after pharmacists' interventions. However, since these may not be the
most appropriate techniques for specific pharmacotherapy interventions, disease-specific methods
should also be considered.
Centers or individuals who want to evaluate patient outcomes that result from pharmacists' interventions should utilize instruments that have been
developed and evaluated by experts.
When appropriate, patient outcomes after pharmacists' interventions and primary care activities
should be assessed with disease-specific instruments that have been validated appropriately.

Primary Care, Clinical Pharmacy Services in (ACCP)

806

4. The choice of generic andlor disease-specific

instrument(s), should be made by the multidisciplinary team when patient care is being assessed.

primary care functions, the contractual arrangement

should be viewed as being with the patient.

T e r m i n a t ~ nthe
~

TH
Since primary care often involves an interdisciplinary
team. many health care professionals provide care to the
patient. Clinical pharmacists need to understand the legal
implications of the care they provide, or of their patient
interventions. Some of the medical-legal concepts that
need to be addressed include: what establishes a professional relationship, how to terminate this relationship,
abandonment, and harmful neglect. These issues are rooted
in both tort and contract law. In actions of negligence, four
legal elements must be addressed: duty, breach of this
duty, damage, and causation.201In determining a pharmacists duty, the central question is whether a particular
conduct is a standard of pharmaceutical care. This is often
quite controversial in that there may be certain activities,
such as duty to warm, that are not accepted by all courts as
a standard of care for pharmacists. If it is decided that the
action is not a standard of care, the pharmacist cannot
be held negligent. If it is, then the issues are whether
the pharmacist breached that duty (standard of care),
whether the patient was harmed (and to what extent),
and whether the breach of duty caused the harm.
The essence of primary care is taking responsibility for
the care of the patient to improve outcomes. Therefore,
the following discussion is essential for the pharmacistpatient relationship in primary care.

It is the pharmacist-patient relationship that gives rise to

the pharmacists duty to care.[211The pharmacist-patient
relationship usually involves an expressed or implied
contractual agreement whereby the pharmacist offers to
treat the patient with proper professional skill and the
patient agrees to pay for such treatment. The pharmacist
has the responsibility for practicing all facets of the
profession competently. This could involve, for example,
drug distribution. providing primary care, patient monitoring. patient and provider consultationleducation, and
other activities. As a result, the legal principles governing contract formation apply to the establishment of
the pharmacist-patient relationship. At issue, however,
is whether this contractual arrangement really exists
between the pharmacist and the patient or whether it is
between the pharmacist and some other entity such as
the physician. The answer may depend on what the
pharmacist is actually doing. If the pharmacist provides

If a pharmacist-patient relationship exists and it is to be

terminated. the pharmacist must give the patient sufficient notice so that he may secure other professional
care.[211Even though the pharmacists powers in terminating the relationship are limited, the patient has
broad powers in terminating the relationship. The patient
is free to unilaterally terminate the relationship at any
time. From the moment the pharmacist is dismissed or
discharged, he is relieved of all future professional responsibility to the patient.

Once established, the pharmacist-patient relationship

imposes a duty of care upon the pharmacist that continues
as long as attention is required, unless the pharmacist
gives sufficient notice of termination or is discharged.[211
While this case law currently only applies to physicians,
pharmacists who assume a caregiver role would also be
subject to this duty. To recover on the theory of abandonment. the plaintiff must prove the following:
a) Existence of a pharmacist-patient relationship.
b) Unilateral severance by the pharmacist without
reasonable notice and without providing an adequate substitute.
c) Necessity of continuing pharmaceutical attention.
d) Proximate cause.
e) Damages.
A pharmacist is immune from the abandonment charge
when the patient voluntarily chooses not to return or
discharges the pharmacist.
Abandonment may thus occur in two ways: through
explicit withdrawal from a case or failure to attend the
patient with due diligence. If the pharmacist fails to attend
the patient with due diligence, he may also be liable under
negligence principles. If he prematurely terminates the
relationship despite the patients continued need for care,
he may also have abandoned the patient. The pharmacist
has a definite right to withdraw from the case provided he
gives the patient reasonable notice so that a patient may
secure other attention. Failure by the patient to cooperate
with the pharmacist may justify termination of the
professional relationship by the pharmacist. The pharmacist is not justified in abandoning the patient unless
the patient obstinately refuses treatment. Differences of

Primary Care, Clinical Pharmacy Services in (ACCP)

opinion on the factors surrounding a case may occur.

Therefore, it would be prudent for the pharmacist to
document carefully events and to offer to obtain a substitute clinician for the patient, and even then alternative
care arrangements must be made.

Decisions concerning frequency of patient visits are an

important medical-legal issue. Pharmacists can be held
liable for harmful neglect, an act of negligence involving
nondiligent care of the patient. Courts have ruled, A
physician is not chargeable with neglect on account of the
intervals elapsing between visits, where the injury
requires no attention during the intervals, but is negligent
where attention is required.[221
The establishment for proximate or legal causation is the first step.[231A factual link between the pharmacists conduct and the patients injury and whether the
pharmacist could have foreseen the harm must be determined. The plaintiff must compare what did occur with
what would have occurred if contrary-to-fact conditions
existed. As an example, in a case involving a pharmacist, if
the pharmacist had provided more frequent visits, would a
more favorable outcome have resulted? The plaintiff
would have to prove, by a preponderance of the evidence,
that the infrequency of visits was the cause of damages to
him. In addition, even if it is established that the pharmacists conduct caused the patients injury, a question of
forseeability may be raised. In general, unless the pharmacist could have foreseen that harm would occur, there
will be no liability. The issue of foreseeability would most
likely be part of the determination of duty. Many of the
consensus statements and guidelines included in this paper
describe appropriate intervals of follow up that, if
followed, might reduce the liability of clinical pharmacists.
The jury would be instructed not to consider a pharmacists workload as a legitimate determination of frequency
of follow-up care. Pharmacists should be aware that having
more patients than time allows does not relieve them of
their responsibility to provide proper follow-up care.
Pharmacists do not carry the sole burden of what
happens to their patients during intervals between appointments. Patients also have responsibilities with regard to
the management of their illnesses. The Supreme Court
of Maine ruled it is the duty of a patient to follow the
reasonable instructions and submit to the reasonable
treatment prescribed by his physician or surgeon.[241 If
the patient fails in his duty and his conduct directly
contributes to the injury, he may be precluded from or
limited in seeking damages. Some state laws provide for
contributory negligence where any negligence by the
plaintiff completely bans recovery. Other states have

807

comparative negligence where blame is essentially

apportioned between the plaintiff and defendant.
In summary, pharmacists decisions regarding followup care are subject to legal scrutiny. As standard guidelines concerning the appropriate frequency of follow-up
visits for outpatient management of most diseases are not
routinely available, clinicians are vulnerable to actions for
harmful neglect. Lacking such standards, a jury of laypersons listens to expert testimony and decides whether
appropriate care was given. Busy workloads of pharmacists who service a large number of patients are not
considered a defense against harmful neglect. If a practitioner cannot provide adequate care to each patient, an
equally competent substitute must be named. Finally, it is
essential to remember that the patient has obligations in
the management of his own health. To document appropriate pharmacists advice to patients, written instructions should be provided that clearly and specifically
outline what the patient should do during intervals between visits, and full and appropriate records of patient
visits must be maintained.

This Task Force report is designed to provide administrators and pharmacy practitioners with recommendations
that assist them in establishing and evaluating pharmacy
services and assessing patient outcomes in ambulatory/
primary care. Each setting will have unique features requiring specific processes be tailored to that institution
or clinic. By utilizing the outcome instruments, practice
guidelines, and other materials listed in this report, the
clinician should be able to establish a valuable practice
in most primary care settings.

This article was written in collaboration with Joseph L.

Fink 111, JD, and Francis B. Palumbo, PhD, JD, who
assisted with the legal discussions and Kathleen M.
Bungay, PharmD, and Eleanor Perfetto, PhD, who
provided significant guidance and advice with the health
care process and outcomes sections.
The article was written by the following ACCP Task
Force on Ambulatory Care Clinical Pharmacy Practice:
William Linn, Pharm.D. (Chair), Barry L. Carter,
Pharm.D., FCCP, BCPS (Board Liaison); Betsy Carlisle,
Pharm.D.; Allan Ellsworth, Pharm.D., BCPS; Timothy
Ives, PharmD., BCPS; Susan Maddux, Pharm.D., BCPS;
Patricia Taber, Pharm.D, BCPS. Approved by the ACCP
Board of Regents on May 4, 1994.

Primary Care, Clinical Pharmacy Services in (ACCP)

808

Appendix 1 Application for scope of practice

Clinical Pharmacy Specialists
Name:
Position on hospital staff
Pharmacy school(s):
Date(s) of graduation:
Graduate degree.
Graduation:
NoBoard certified in pharmacotherapy: YesBoard certified in other pharmacy specialty?: YesSpecialty area:
Stares currently licensed:

No-

NAP

The following are the clinical scope of practices granted to you as a member of the staff of the
Hospital (Clinic),
located in
(state?. These determinations were made through a thorough review of your education,
(city).
training, and experience, and demonstrated competence by the Professional Standards Board and approved by the Director. If you
change positions and/or if your duties change (i.e., a geriatric clinical pharmacist moves to medical oncology), then you must
reapply for practices specific to that area
~

Areas of Practice:
A = Ambulator). Care

4.
Routine duties: Routine duties are defined as those duties that are performed on a regular, repetitive basis.
(1) Category A-1. Routine duties that require review by the physician supenisor who will note concurrence or addendum as
indicated Countersignature of the medical record is required within 2 4 hours.
Requested
taking and recording verbal orders from physicians
A
(2) Category A-2: Routine duties that do not require review by the physician supenisor unless so indicated These duties v.4 be

remewed by the physician supervisor on a regular basis rhrough a random sampling process. Results of this
review wll be discussed with the clinical pharmacist as appropnate.
Requested
* provision of formal wntten consultations upon request
A
in the areas of pharmacotherapy and pharmacokinetics
* provision of written initial assessments in the progress notes
A
A
provision of follow-up notes within the progress notes
* taking medicatiodtherapeutic histones
A
* measuring ma1 signs and performing physical examinations
of relevant organ systems for the purpose of monitoring
A
drug therapy
* collecting laboratory specimens (i.e., drawing blood)
A
* order the followng noninvasive tests:
(a) iaboratory tests (e.g., PT, CBC)
(b) EKGs
( c ) Holter monitors
A
(d) PFTs
A
(e) echocardiograms
A
(0x-rays (e.g., CXR)
A
* order appropriate consultations from the following services:
A
(a) dental
A
(b) dietetics
A
(c) medical specialties
A
(d) psychiatry
A
(e) psychology
(0 radiology
A
(& social work
A
(h) surgical specialties (old problems)

(Continued)

Primary Care, Clinical Pharmacy Services in (ACCP)

ix B

809

Application for scope of practice (Continued)

B. Non-RoutineJNon-Emergency Duties:
Requested
* authority to m t e prescriptions for medication refills for
medical problems that are stable in patlents followed in
outpatient clinics, The clinical pharmacist is not authorized
to write prescriptions that are used to initiate any form of
drug therapy.
* authority to make adjustments in dosage as clinically
indicated for a period of up to 3 months between
physician visits using the following classes of drugs:
1. antihistamine drugs
2 antiinfective agents
3 . antineoplastic agents

4. autonomic drugs
5. blood formation and coagulation
6. cardiovascular drugs
7. central nervous system agents
8. gastrointestinal drugs
9. hormones and synthetic substitutes
10. respiratory smooth muscle relaxants
limited authorization to approve the use of restricted or
nonformulary medications when the use of such agents
is within the established guidelines or approved cntena
for use at this facility (i.e., antibiotics, chemotherapy)

A
{indicates not applicable to this ambulatory care
pharmacist)
A
A
A
A
A

C. Emergency Duties: Carried out for patients in life-threatening situations where a physician is not immediately available The
clinical pharmacist initiates this activlty but makes every effort to summon a physician as soon as possible
(i,e,,cardiopulmonary resuscitation, and, if advanced cardiac life support-certified, electrodefibrillation).

D. Miscellaneous Duties: Those duties that do not fall into the first category.
A
conduct clinical research protocols
0

I do hereby request the above outlined scope of practices. 1 have read and agree to abide by the bylaws of the
Hospital.
Signature of applicant

Date

Signature of physician supervisor

Date

Chief, Pharmacy Service

Date

Chief of Staff

Date

Director

Date

~ p p e ~ d 2i x Evaluating process of care: Example quality assurance in primary care

Medical Records will be reviewed on a quarterly basis. Twenty-five charts will be randomly selected and reviewed for the
following items:
1. Progress notes written in an appropriate S.O.A.P. format.
2. Determine if the subjective and objective information is consistent with the assessment and plan.
3. Past medical history and family history is obtained at least once for each patient.
4. Social, diet, and exercise history is recorded at least every 4 months.
5. Medication history recorded at least once.
6. Current prescription and nonprescription medication recorded on each visit.
7. Compliance is assessed on each visit.
8. Each visit contains thorough questioning concerning disease control, signs or symptoms of disease progression or new
complications, and signs or symptoms of adverse reactions.
9. Each visit documents appropriate objective information such as laboratory, physical assessment data, vital signs, etc.
10. All patient counseling concerning drug therapy, compliance, diet. exercise, and other lifestyle factors are recorded.
(Continued)

Primary Care, Clinical Pharmacy Services in (ACCP)

810

A ~ ~ e 2n ~Evaluating
~ x
process of care: Example quality assurance in primary care (Continued)
11. Therapeutic goals are clearly stated.
12. Appropriate recommendations and drug regimen changes are made and documented in the plan.
13. Documentation of any actions that are beyond the scope of practice that were authorized by a physician.
14. Appropriate timing of follow-up visit is included in every plan.

A p ~ e n ~ 3i x Treatment guidelines and review articles

Hypertension guidelines
1. The fifth report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC V). Arch
Intern Med 1993; 153: 154-83.
2. Frohlich ED, Apstein C, Chobanian AV, et al. The heart in hypertension. N Engl J Med 1992; 327: 998-1008.
3. National High Blood Pressure Education Program. National High Blood Pressure Education Program Working Group report on
hypertension and chronic renal failure. Arch Intern Med 1991; 151: 1280-7.
4. National High Blood Pressure Education Program. National High Blood Pressure Education Program Working Group report on
primary prevention of hypertension. Arch Intern Med 1993; 153: 186-208.
5. National High Blood Pressure Education Program Working Croup report on the heart in hypertension. National High Blood
Pressure Education Program. U.S. Department of Health and Human Services. NIH Publication No. 91-3033. September 1991.
6. National High Blood Pressure Education Program Working Group. National High Blood Pressure Education Program Working
Croup report on hypertension in the elderly. Hypertension 1994; 23: 275-85.
7. National High Blood Pressure Education Program Working Group. National High Blood Pressure Education Program Working
Group report on hypertension in diabetes. Hypertension 1994; 23: 145-58.
8. Bussey HI, Hawkins DW. Hypertension. In: Carter B, Angaran D, Sisca T, eds. Pharmacotherapy self-assessment program, 1st
edition. Kansas City: American College of Clinical Pharmacy, 1991: 1-26.
9. Bussey HI, Hawkins DW. Hypertension. In: Carter BL, Angaran DM, Lake KD, Raebel MA, eds. Pharmacotherapy selfassessment program, 2nd edition. Kansas City: American College of Clinical Pharmacy, In press.
Diabetes guidelines
10. Lebovitz HE, Clark CM, DeFronzo RA, et ai., for the American Diabetes Association Clinical Education Program. Physicians
guide to non-insulin-dependent (type 11) diabetes. Diagnosis and treatment, 2nd edition. American Diabetes Association, 1990.
11. American Diabetes Association. Clinical practice recommendations, 1992- 1993. Diabetes Care 1993; 16 (suppl 2): 1-113.
12. The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development
and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 1993; 329: 977-86.
13. Bartels DW. Diabetes mellitus. In: Carter B, Angaran D, Sisca T, eds. Pharmacotherapy self-assessment program, 1st edition.
Kansas City: American College of Clinical Pharmacy, 1993: 145-167.
14. Bartels DW. Diabetes mellitus. In: Carter BL, Angaran DM, Lake KD, Raebel MA, eds. Pharmacotherapy self-assessment
program, 2nd edition. Kansas City: American College of Clinical Pharmacy, In press.
Hyperlipidemia guidelines
15. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Summary of the second report of the
National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood
Cholesterol in Adults (Adult Treatment Panel 11). JAMA 1993; 269: 3015-23.
16. Israel MK, McKenney JM. Hyperlipidemias. In: Carter B, Angaran D, Sisca T, eds. Pharmacotherapy self-assessment program,
1st edition. Kansas City: American College of Clinical Pharmacy, 1991: 27-47.
17. Israel MK. Hyperlipidemias. In: Carter BL, Angaran DM, Lake KD, Raebel MA, eds. Pharmacotherapy self-assessment program,
2nd edition. Kansas City: American College of Clinical Pharmacy, In press.
Heart failure guidelines
18. Chow MSS, Scheife RT, eds. Therapeutic and research strategies for congestive heart failure. Pharmacotherapy 1993;13 (5 pt 2):
7 1 s-99.
19. Munger MA, Stanek EJ. Heart failure. In: Carter B, Angaran D, Sisca T, eds. Pharmacotherapy self-assessment program, 1st
edition. Kansas City: American College of Clinical Pharmacy, 1991: 85-99.
20. Stanek EJ, Moser LR, Munger MA. Heart failure. In: Carter BL, Angaran DM, Lake KD, Raebel MA, eds. Pharmacotherapy selfassessment program, 2nd edition. Kansas City: American College of Clinical Pharmacy, In press.
(Continued)

811

Primary Care, Clinical Pharmacy Services in (ACCP)

Appendix 3 Treatment guidelines and review articles (Continued)

21. Bmtsaert DL, Sys SU, Gillebert TC. Diastolic failure: pathophysiology and therapeutic implications. J Am Coll Cardiol 1993; 22:
3 18-25.
22. Heart failure: evaluation and care of patients with left ventricular systolic dysfunction. Agency for Health Care Policy and
Research (under development).
Coronary artery disease guidelines
23. Frishman WH. Conference on optimizing antianginal therapy. Am J Cardiol 1992; 70: 16-76,
24. Hamilton SF. Angina pectoris. In: Carter B, Angaran D, Sisca T, eds. Pharmacotherapy self-assessment program, 1st edition.
Kansas City: American College of Clinical Pharmacy, 1991: 49-64.
25. Hamilton SF. Angina pectoris. In: Carter BL, Angaran DM, Lake KD, Raebel MA, eds. Pharmacotherapy self-assessment
program, 2nd edition. Kansas City: American College of Clinical Pharmacy, In press.
26. Diagnosis and management of unstable angina. Agency for Health Care Policy and Research (under development).
Asthmdchronic obstructive pulmonary disease guidelines
27. The Expert Panel on the Management of Asthma. National Asthma Education Program. Guidelines for the diagnosis
and management of asthma. National Asthma Education Program. Office of Prevention, Education, and Control. National
Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland 20892. NIH Publication No. 91-3042,
August 1991.
28. Ferguson GT, Cherniack RM. Management of chronic obstructive pulmonary disease. N Engl J Med 1993; 328: 1017-22.
29. Kelly HW. Asthma. In: Carter B, Angaran D, Sisca T, eds. Pharmacotherapy self-assessment program, 1st edition. Kansas City:
American College of Clinical Pharmacy, 1992: 3-16.
30. Kelly H W .Asthma. In: Carter BL, Angaran DM, Lake KD, Raebel MA, eds. Pharmacotherapy self-assessment program, 2nd
edition. Kansas City: American College of Clinical Pharmacy, In press.
31. Stratton MA. Chronic obstructive pulmonary disease. In: Carter B, Angaran D, Sisca T, eds. Pharmacotherapy self-assessment
program, 1st edition. Kansas City: American College of Clinical Pharmacy, 1992: 17-38.
32. Stratton MA, Noyes M. In: Carter BL, Angaran DM, Lake KD, Raebel MA, eds. Pharmacotherapy self-assessment program, 2nd
edition. Kansas City: American College of Clinical Pharmacy, In press.
Peptic ulcer disease guidelines
33. Sol1 AH. Pathogenesis of peptic ulcer and implications for therapy. N Engl J Med 1990; 322: 909-16.
34. Fish DN, Siepler JK. Gastroesophageal reflux disease. In: Carter B, Angaran D, Sisca T, eds. Pharmacotherapy self-assessment
program, 1st edition. Kansas City: American College of Clinical Pharmacy, 1992: 123-33.
35. Fish D. Gastroesophageal reflux disease. In: Carter BL, Angaran DM, Lake KD, Raebel MA, eds. Pharmacotherapy selfassessment program, 2nd edition. Kansas City: American College of Clinical Pharmacy, In press.
36. Piscitelli SC, Garnett WR. Peptic ulcer disease. In: Carter B, Angaran D, Sisca T, eds. Pharmacotherapy self-assessment
program, 1st edition. Kansas City: American College of Clinical Pharmacy, 1992: 145-57.
37. Piscitelli SC. Zollinger-Ellison disease/NSAID-induced gastropathy/peptic ulcer disease. In: Carter BL, Angaran DM, Lake KD,
Raebel MA, eds. Pharmacotherapy self-assessment program, 2nd edition. Kansas City: American College of Clinical Pharmacy,
In press.
38. Hixson LJ, Kelly CL. Current trends in the pharmacotherapy for gastroesophageal reflux disease. Arch Intern Med 1992; 152:
717-23.
39. Hixson LJ, Kelly CL. Current trends in the pharmacotherapy for peptic ulcer disease. Arch Intern Med 1992; 152: 726-32.
40. National Institutes of Health Consensus Development Conferences Statement. Helicobacter pylori in peptic ulcer disease.
February 7-9, 1994.
Seizure disorders guidelines
41. Scheuer ML, Pedley TA. The evaluation and treatment of seizures. N Engl J Med 1990; 323: 1468-74.
42. Miyahara RK. Seizure disorders. In: Carter B, Angaran D, Sisca T, eds. Pharmacotherapy self-assessment program, 1st edition.
Kansas City: American College of Clinical Pharmacy, 1992: 47-61.
Thromboembolic disorders guidelines
43. Dalen JE, Hirsh J, for the Third ACCP Consensus Conference on Antithrombotic Therapy. Chest 1992; 102: 3038-549.
44. Carter BL. Therapy of acute thromboembolism with heparin and warfarin. Clin Pharm 1991; 10: 503-18.
45. Rodvold KA, Erdman SM. Pulmonary embolism. In: Carter B, Angaran D, Sisca T, eds. Pharmacotherapy self-assessment
program, 1st edition. Kansas City: American College of Clinical Pharmacy, 1992: 39-53.
(Continued)

812

Primary Care, Clinical Pharmacy Services in (ACCP)

Appendix 3 Treatment guidelines and review articles (Continued)

~~

46 Rodvold KA, Erdman SM Thrombosis In Carter BL. Angaran DM, Lake KD, Raebel MA. eds Pharmacotherapy selfassessment progiam, 2nd edition Kansas City American College of Clinical Pharmacy, In press
Estrogen replacement therapy guidelines
47. American College of Physicians. Guidelines for counseling postmenopausal women about preventive hormone therapy. Ann
intern Med 1992; 117: 1038-41.
48. Lourwood DL. Estrogen replacement therapy. In: Carter B, Angaran D, Sisca T, eds. Pharmacotherapy self-assessment program,
1st edition. Kansas City: American College of Clinical Pharmacy, 1993: 189-202.
49. Lourwood DL. Hormone replacement therapy. In: Carter BL, Angaran DM, Lake KD, Raebel MA, eds. Pharmacotherapy selfassessment program. 2nd edition. Kansas City: American College of Clinical Pharmacy, In press.
50. Grady D, Rubin SM. Hormone therapy to prevent disease and prolong life in postmenopausal women. Ann Intern Med 1992;
117: 1016-41.
5 1. Wood H, Wang-Cheng R. Postmenopausal hormone replacement: are two hormones better than one? J Gen Intern Med 1993; 8:
451-8.
52. Belchetz PE. Hormonal treatment of postmenopausal women. N Engl J Med 1994; 330: 1062-71.
Rheumatologic disorders guidelines
53. Anonymous. Drugs for rheumatoid arthritis. Med Lett Drugs Ther 1991; 33: 65-70.
54. Harris ED. Rheumatoid arthritis: pathophysiology and implications for therapy. N Engl J Med 1990; 322: 1277-89.
Depression guidelines
55. Clinical practice guidelines. Depression in primary care, volume 1. Detection and diagnosis. U S . Department of Health and
Human Services. Public Health Service, Agency for Health Care Policy and Research. AHCPR Publication No. 93-0550, April
1993.
56. Clinical practice guidelines. Depression in primary care. volume 2. Treatment of major depression. US.Department of Health
and Human Services. Public Health Service, Agency for Health Care Policy and Research. AHCPR Publication No. 93-0550,
April 1993.
57. American Psychiatric Association. Practice guidelines for major depressive disorders in adults, 2nd edition. Washington, DC,
1993.
58. Crimsley SR. Depression. In: Carter B, Angaran D, Sisca T, eds. Pharmacotherapy self-assessment program, 1st edition. Kansas
City: American College of Clinical Pharmacy, 1992: 127-50.

Appendix 4 Bibliography on patient outcomes measurement

Generic tools
1. Stewart AL, Ware JE Jr, eds. Measuring functioning and well-being: the medical outcomes study approach. The Rand
Corporation. Durham. NC: Duke University Press, 1992.
2. Parkerson GR, Gehlbach SH. Wagner EH: et al. The Duke-UNC health profile: an adult health status instrument for primary care.
Med Care 1981; 19: 806-28.
3. 'Hunt SM,McEwen J. McKenna SP. Measuring health status: a tool for clinicians and epidemiologists. J R Coll Gen Pract 1985;
35: 185-8.
4. Nelson EC, Wasson JH. Kirk JQ. Assessment of function in routine clinical practice: description of the COOP chart method and
preliminary findings. J Chronic Dis 1987; 40 (suppl 1): 55s-63.
5 . Stewart AL, Hays RD, Ware JE. The MOS short-form general health survey: reliability and validity in a patient population. Med
Care 1988; 26: 724-35.
6. Ware JE, Snow K; Kosinski M, et al. SF-36 health survey manual and interpretation guide. Boston: Nimrod Press, 1993.
7. Bergner M, Bobbitt RA, Carter WB. et al. The sickness impact profile: conceptual formulation and methodology for the
development of a health status measure. Int J Health Serv 1976; 6: 393-415.
The Nottingham Health Profile
Disease-specific tools to measure outcomes
Hypertension outcomes
1. Flack JM. Grimm RH. HypertensiodLipid Form 5.1, Bloomington, MN: Health Outcomes Institute, 1993. (200 Killebrew Dr.,
Suite 122, Bloomington. MN 55425).
(Continued)

Primary Care, Clinical Pharmacy Services in (ACCP)

813

Appendix 4 Bibliography on patient outcomes measurement (Continued)

2. Bulpitt CJ, Fletcher AE. Quality of life in hypertensive patients on different antihypertensive treatments: rationale for methods
employed in a multicenter randomized controlled trial. J Cardiovasc Pharm 1985; 7 (suppl 1): 137-45.
3. Chang SW, Fine R, Siege1 D, et al. The impact of diuretic therapy on reported sexual function. Arch Intem Med 1991; 151:
2402-8.
4. Croog SH, Levine S, Testa MA, et al. The effects of antihypertensive therapy on the quality of life. N Engl J Med 1986; 314:
1657- 64.
5. Levine S, Croog S, Sudilovsky A, et al. Effects of antihypertensive medications on vitality and well-being. J Fam Pract 1987; 25:
357-63.
6. Testa MA, Anderson RB, Nackley JF, et al. Quality of life and antihypertensive therapy in men: a comparison of captopril with
enalapril. N Engl J Med 1993; 328: 907-13.
7. Testa MA, Sudilovsky A, Rippey RM, et al. A short form for clinical assessment of quality of life among hypertensive patients.
Am J Prev Med 1989; 5: 82-9.
8. The Treatment of Mild Hypertension Research Group. The treatment of mild hypertension study: a randomized, placebo-conrolled trial of a nutritional-hygienic regimen along with various drug monotherapies. Arch Intern Med 1991; 151: 1413-23.
9. Watters K, Campbell B. Can an antihypertensive agent be both effective and improve the quality of life? A multicenter study
with indapamide. Br J Clin Prac 1986; 40: 239-44.
10. Wenger NK, Mattson ME, Furberg CD, Elinson J, eds. Assessment of quality of life in clinical trials of cardiovascular therapies.
New York: Le Jacq Publishing Inc., 1984.
Diabetes outcomes
11. Given CW. Measuring the social psychological health states of ambulatory chronically ill patients: hypertension and diabetes as
tracer conditions. J Comm Health 1984; 9: 179-95.
12. Hanestad BR, Polit RN. Perceived quality of life in a study of people with insulin-dependent diabetes mellitus using the
Hornquist model. Qua1 Life Res 1994; 3: 79.
13. Hanestad BR, Homquist JQ, Albreksten G. Self-assessed quality of life and metabolic control in persons with insulin-dependent
diabetes mellitus (IDDM). Scand J SOCMed 1991; 19: 57-65.
14. Kaplan SH. Patient reports of health status as predictors of physiologic health measures in chronic disease. J Chronic Dis 1987;
40: 278-35.
15. Marquis KH, Ware JE, Johnston R, et al. Appendix B to summary report: an evaluation of published measures of diabetes selfcare variables. Publication No. N-1152-HEW. Santa Monica, CA: The Rand Corporation, June 1979.
16. Nerenz DR, Repasky DP, Whitehouse FW,et al. Ongoing assessment of health status in patients with diabetes mellitus. Med
Care 1992; 30 (suppl 5): MS112-24.
17. Testa MA, Simonson DC. Measuring quality of life in hypertensive patients with diabetes. Postgrad Med J 1988; 64 (suppl3): 50-8.
18. The Diabetes Control and Complications Trial (DCCT) Research Group. Reliability and validity of a diabetes quality-of-life
measure for the Diabetes Control and Complications Trial. Diabetes Care 1988; 11: 725-32.
19. Wenneker MB, Mchorney CA, Kieszak SM, et al. The impact of diabetes severity on quality of life: results from the medical
outcomes study [abstr]. Clin Res 1991; 39: 612A.
Hyperlipidemia outcomes
20. Flack JM. Grimm RH. HypertensionLipid Form 5.1. Bloomington, MN: Health Outcomes Institute, 1993. (200 Killebrew Dr..
Suite 122, Bloomington, MN 55425).
Heart failure outcomes
21. Guyatt GH, Nogradi S, Halcrow S, et al. Development and testing of a new measure of health status for clinical trials in heart
failure. J Gen Intern Med 1989; 4: 101-7.
22. Bulpitt CJ, Fletcher AE. Measurement of the quality of life in congestive heart failure-influence of drug therapy. Cardiovasc
Drug Ther 1988; 2: 419-24.
23. Feinstein AF, Fisher MB, Pigeon JG. Changes in dyspnea-fatigue ratings as indicators of quality of life in the treatment of
congestive heart failure. Am J Cardiol 1989; 64: 50-5.
24. Gorkin L, Norvell NK, Rosen R, et al. Assessment of quality of life as observed from the baseline data of the Studies of Left
Ventricular Dysfunction (SQLVD) trial quality-of-life substudy. Am J Cardiol 1993; 7 1: 1069-73.
25. Guyatt G. Methodological problems in clinical trials in heart failure. J Chronic Dis 1985; 38: 353-63.
26. Massie BM, Berk MR, Brozena SC, et al. Can further benefit be achieved by adding flosequinan to patients with congestive heart
failure who remain symptomatic on diuretic. digoxin, and an angiotensin converting enzyme inhibitor? Results of the
Flosequinan-ACE Inhibitor Trial (FACET). Circulation 1993; 88: 492-501.
(Conrinued)

Primary Care, Clinical Pharmacy Services in (ACCP)

814

Appendix 4 Bibliography on patient outcomes measurement (Continued)

27. Rector TS; Tschumperlin LK, Kubo SH, et al. Clinically significant improvements in the living with heart failure questionnaire
score as judged by patients with heart failure. Qual Life Res 1994; 3: 60-1.
28. Rector TS. Outcomes assessment: functional status measures as therapeutic endpoints for heart failure. Top Hosp Pharm Manag
1990: 10: 37-43.
29. Rector TS, Cohn JN. Assessment of patient outcome with the Minnesota living with heart failure questionnaire: reliability and
validity during a randomized, double-blind, placebo-controlled trial of pimobendan. Am Heart J 1992; 124: 1017-25.
30. Rector TS, Kubo SH, Cohn JN. Patients self-assessment of their congestive heart failure-Part 2: content, reliability and validity
of a new measure, the Minnesota living with heart failure questionnaire. Heart Fail 1987; 3: 198-209.
31. Rector TS, Kubo SH, Cohn JN. Validity of the Minnesota living with heart failure questionnaire as a measure of therapeutic
response to enalapril or placebo. Am J Cardiol 1993; 71: 1106-7.
32. Retchin SM. Brown B. Elderly patients with congestive heart failure under prepaid care. Am J Med 1991; 90: 236-42.
33. Romm FJ, Hulka BS, Mayo F. Correlates of outcomes in patients with congestive heart failure. Med Care 1976; 15: 765-76.
34. Wiklund I, Lindvall K, Swedberg K; et al. Self-assessment of quality of life in severe heart failure: an instrument for clinical use.
Scand J Psycho1 1987; 28: 220-5.
Coronary artery disease outcomes
35. Vaisrub S. Quality of life manque. JAMA 1976; 236: 387.
36. Permanyer-Miralda G, Alonso J, Anto JM, et al. Comparison of perceived health status and conventional functional evaluation in
stable patients with coronary artery disease. J Clin Epidemiol 1991; 44: 779-86.
37. Smith HC, Frey RL, Piehler JM. Does coronary bypass surgery have a favorable influence on the quality of life? Cardiovasc Clin
1983; 12: 253-64.
38. VandenBurg MJ. Measuring the quality of life of patients with angina. In: Walker SR, Rosser RM, eds. Quality of life:
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39. Westaby S, Sapsford RN, Bentall HH. Return to work and quality of life after surgery for coronary artery disease. Br Med J 1979;
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40. Spertus JA, Winder JA. The Seattle angina questionnaire: validation of a new functional status measure for patients with
coronary artery disease (submitted 1993).
41. Pryor DB. Angina Form 9.1. Bloomington. MN: Health Outcomes Institute, 1993. (200 Killebrew Dr., Suite 122, Bloomington,
MN 55425).
Asthmdchronic obstructive pulmonary disease outcomes
42. Alonso J, Auto JM, Gonzalez M, et al. Measurement of general health status of non-oxygen dependent chronic obstructive
pulmonary disease patients. Med Care 1992; 30: MS125-35.
43. Barber BL. Santanello NC, Epstein RS. Clinical meaning of change in an asthma-specific questionnaire. Qual Life Res 1994; 3:
58-9.
44. Bishop J, Carlin J, Nolan T. Evaluation of the properties and reliability of a clinical severity scale for acute asthma in children. J
Clin Epidemiol 1992; 45: 71-6.
45. Eakin EG, Kaplan RM, Ries AL. Measurement of dyspnea in chronic obstructive pulmonary disease. Qual Life Res 1993; 2:
181-91.
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Chronic Dis 1985; 38: 517-24.
47. Guyatt GH, Townsend MB, Pugsley SO, et al. Quality of life in patients with chronic airflow limitations. Br J Dis Chest 1987;
81: 45-54.
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42: 773-8.
49. Hyland ME, Finnis S, Irvine SH. A scale for assessing quality of life in adult asthma sufferers. J Psychosoc Res 1991; 35: 99- 110.
50. Juniper EF, Guyatt GH, Griffith LE. Determining a minimal important change in a disease-specific quality of life questionnaire. J
Clin Epidemiol 1994; 47: 81-7.
51. Juniper EF, Guyatt GH. Epstein RS, et al. Evaluation of impairment of health related quality of life in asthma: development of a
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52. Bethel RA. Asthma Form 10.1. Bloomington, MN: Health Outcomes Institute, 1993. (200 Killebrew Dr., Suite 122,
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53. Bethel RA. COPD Form 15.1. Bloomington, MN: Health Outcomes Institute. 1993. (200 Killebrew Dr., Suite 122, Bloomington,
MN 55425).
(Continued)

Primary Care, Clinical harmacy Services in (ACCP)

815

ix 4 Bibliography on patient outcomes measurement (Continued)

Peptic ulcer disease outcomes
54. Dimenas E: Glise H, Hallerback B, et al. Quality of life in patients with upper gastrointestinal symptoms. An improved
evaluation of treatment regimens? Scand J Gastroenterol 1993; 28: 681 -7.
55. Garratt AM, Ruta DA: Abdalla MI, et al. The SF-36 health survey questionnaires: an outcome measure suitable for routine use
within the NHS? Br Med J 1993; 306: 1440-4.
56. Guyatt GH, Mitchell A, Irvine E, et al. A new measure of health status for clinical trials in inflammatory bowel disease.
Gastroenterology 1989; 96: 804- 10.
57. Pincus T, Griffin M. Gastrointestinal disease associated with non-steroidal anti-inflammatory drugs: new insights from
observational studies and functional status questionnaires. Am J Med 1991; 91: 209- 12.
Seizure disorder outcomes
58. Baker GA. Smith DF, Dewey M, et al. The initial development of a health-related quality of life model as an outcome measure in
epilepsy. Epilepsy Res 1993; 16: 65-81.
59. Baker GA, Smith DF, Dewey M, et al. The development of a seizure severity scale as an outcome measure in epilepsy. Epilepsy
Res 1991; 8: 245-51.
60. Chaplin JE, Uepez R. Shorvon S. et al. A quantitative approach to measuring the social effects of epilepsy. Neuroepidemiology
1990; 9: 151-8.
61, Jacoby A, Baker G, Smith D. et al. Measuring the impact of epilepsy: the development of anovel scale. Epilepsy Res 1993; 16: 83-8.
62. Jacoby A. Epilepsy and the quality of everyday life: findings from a study of people with well-controlled epilepsy. SOCSci Med
1992; 34: 657-66.
63. Jacoby A. Johnson A, Chadwick D. Psychosocial outcomes of antiepileptic drug discontinuation. Epilepsia 1991; 33: 1123-31.
64. Perrine KR. A new quality-of-life inventory for epilepsy patients: interim results. Epilepsia 1993; 34 (suppl 4): S28-33.
65. Smith D, Baker G. Davies G, et al. Outcomes of assessing treatment with lamotrigine in partial epilepsy. Epilepsia 1993; 34:
3 12-22.
66. Smith DF, Baker GA, Dewey M. et al. Seizure frequency, patient-perceived seizure severity and the psychosocial consequences
of intractable epilepsy. Epilepsy Res 1991; 9: 231-41.
67. Vickrey BG. A procedure for developing a quality-of-life measure for epilepsy surgery patients. Epilepsia 1993; 344 (suppl4):
S22-7.
68. Vikrey BG, Hays RD, Brook RH, et al. Reliability and availability of the Katz adjustment scales in an epilepsy sample. Qua1 Life
Res 1992; 1: 63-72.
69. Wagner AK, Bungay KM, Bromfield EB, et al. Health-related quality of life of adult person with epilepsy as compared with
health-related quality of life of well persons. Epilepsia 1993; 6: 5 .
70. Wagner AK, Keller S, Baker GA, et al. Improving health-related quality of life measures for use with people with epilepsy.
Epilepsia 1993; 2: 30.
71. French J. The long-term therapeutic management of epilepsy. Ann Intern Med 1994; 120: 411-22.
Estrogen replacement therapy outcomes
72. Daly E, Gray A. Barlow D, et al. Measuring the impact of menopausal symptoms on quality of life. Br Med J 1993; 307: 836-40.
73. Wiklund I, Holst J, Karlberg J. et al. A new methodological approach to the evaluation of quality of life in postmenopausal women.
Maturitas 1992; 14: 21 1-24.
Rheumatologic outcomes
74. Bombardier C, Ware J, Russell J, et al. Auranofin therapy and the quality of life in patients with rheumatoid arthritis. Am J Med
1986; 81: 565-78.
75. Blair PS, Silman AJ. Can clinical trials in rheumatology be improved? Cum Opin Rheumatol 1991; 3: 272-9.
76. Bjelle A. Functional status assessment. Curr Opin Rheumatol 1991; 3: 280-5.
77. Bakker CH, Rutten-van MM, Van Doorslaer E, et al. Health related utility measurement in rheumatology: an introduction.
Patient Educ Counsel 1993; 20: 145-52.
78. Meenan RF. Gertman PM, et al. Measuring health status in arthritis: the arthritis impact measurement scales. Arthritis Rheum
1980: 23: 146-52.
Depression outcomes
79. Alden D, Austin C, Sturgeon R. A correlation between the geriatric depression scale long and short forms. J Gerontol 1989; 44:
124-5.
(Continued)

816

Primary Care, Clinical Pharmacy Services in (ACCP)

Appendix 4 Bibliography on patient outcomes measurement (Continued)

80. Borson S, McDonald GJ, Gayle T, et al. Improvement in mood, physical symptoms, and function with nortriptyline for
depression in patients with chronic obstructive pulmonary disease. Psychosomatics 1992; 33: 190-201.
81. Brooks W, Blair J, John S, et al. The impact of psychologic factors on measurement of functional status: assessment of the
sickness impact profile. Med Care 1990; 28: 793-804.
82. Given C, Stommel M, Given B. et al. The influence of cancer patients symptoms and functional states on patients depression
and family caregivers reaction and depression. Health Psychol 1993; 12: 277-85.
83. GrCgoire J, de Leva1 N, Mesters P, et al. Validation of the quality of life in depression scale in a population of adult depressive
patients aged 60 years and above. Qual Life Res 1994; 3: 51-2.
84. Gurland B, Golden RR, Teresi JA, et al. The short-care: an efficient instrument for the assessment of depression, dementia and
disability. J Gerontol 1984; 39: 166-9.
85. Lambert MJ, Hatch DR, Kingston MD, et al. Zung, Beck and Hamilton rating scales as measures of treatment outcome: a metaanalytic comparison. J Consult Clin Psychol 1986; 54: 54-9.
86. Light RW, Merrill EJ, Despars JA, et al. Prevalence of depression and anxiety in patients with COPD: relationship to functional
capacity. Chest 1985; 87: 35-8.
87. Norris JT, Gallagher D. Wilson A, et al. Assessment of depression in geriatric medical outpatients: the validity of two screening
measures. J Am Geriatr SOC1987; 35: 989-95.
88. Prusoff BA, Klerman GL, Paykel ES. Concordance between clinical assessments and patients self-report in depression. Arch
Gen Psychiatry 1972: 26: 546-52.
89. Radloff LS. The CES-D scale: a self-report depression scale for research in the general population. J Appl Psychol Meas 1977; 1:
385 -401.
90. Revicki DA, Turner R, Brown R, et al. Reliability and validity of a health-related quality of life battery for evaluating outpatient
antidepressant treatment. Qual Life Res 1992; 1: 257-66.
91. Stewart AL, Sherbourne CD, Wells KB, et al. Do depressed patients in different treatment settings have different levels of wellbeing and functioning? J Consult Clin Psychol 1993; 6: 849-57.
92. Stoker MJ, Sunbar GC, Beaumont G. The SmithKline Beecham quality of life scale: a validation and reliability study in
patients with affective disorder. Qual Life Res 1992; 1: 385-95.
93. Tambs K, Moum T. How well can a few questionnaire items indicate anxiety and depression? Acta Psychiatr Scand 1993; 87:
364-7.
94. Tanaka JS, Huba GJ. Confirmatory hierarchical factor analyses of psychological distress measures. J Pers SOCPsychol 1984; 46:
621-35.
95. Tanaka-Matsumi J, Kameoka VA. Reliabilities and concurrent validates of popular self-report measures of depression, anxiety,
and social desirability. J Consult Clin Psychol 1986; 54: 328-33.
96. Wells KB. Commentary: assessment of psychological morbidity in primary care. J Chronic Dis 1987; 40 (suppl 1): 81s-3.
97. Wells KB, Stewart A, Hays RD, et al. The functioning and well being of depressed patients. JAMA 1989; 262: 914-19.
98. Wells KB, Hays RD, Burnam MA, et al. Detection of depressive disorders for patients receiving prepaid for fee-for-service care:
results from the medical outcomes study. JAMA 1989; 262: 3298-3302.
99. Radloff LS. The CES-D scale: a self reported depression scale for research in the general population. Appl Psychol Meas 1977; 1:
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PROFESSIONAL DEVELOPMENT

American College of Clinical Pharmacy,

Kansas City, Missouri, U.S.A.

B NT
A career in a professional association can be an extremely
rewarding way to practice clinical pharmacy while serving the members of the profession. Positions may focus on
many different programmatic areas (Table 1). In addition
to positions in national associations, pharmacists serve
important roles in state and regional associations. There
are also many related biomedical associations in which
pharmacists may be employed.

TY

SlTCQ

Many types of positions are possible within associations.

Those working for large pharmacy associations may have
more than 100 coworkers. Employees of large associations typically have fairly narrow responsibilities and
focus. Within smaller associations, with staffs of 40 or
less, areas of responsibility are broad, and many positions
are combined or do not exist.
Approximately 20 of the 100 employees of the
American Pharmaceutical Association are pharmacists.
Of 20 employees of the Academy of Managed Care
Pharmacy, 4 are pharmacists. The American College of
Clinical Pharmacy, with a staff of 30. employs 6 who are
pharmacists. The American Society of Health-System
Pharmacists. with a staff of approximately 175 persons,
has a larger proportion who are pharmacists due to their
extensive publishing efforts.
Clinical pharmacists within associations are most frequently employed within areas where their backgrounds
are of most benefit. Some of these areas include serving
as the chief executive officer, working with chapter relations, education, government and professional affairs,
marketing, membership, and publications, including the
journals of the association.
Depending on the size of the association staff, clinical
pharmacists may start out working with specific publica-

818

tions, membership and chapter activities, or educational

program planning. As they gain experience and familiarity with their roles, they may take on greater managerial
roles and broader areas of responsibility. Those with the
greatest experience and expertise may move into director,
or vice presidential, positions, or even become the chief
executive officer for the association.
According to the American Society of Association
Executives (ASAE), the average total compensation for
association executives in 1996 ranged from $48,000 to
$1 17,000.] Compensation has increased over the last
few years by percentages greater than business averages
(5-10% for many positions). Many associations use
ASAE survey information. faculty and deans salary data
collected by the American Associations of Colleges of
Pharmacy,[21 and salary data from other segments of
the profession (e.g., managed care pharmacists, industry
pharmacists) as benchmarks for pharmacist executive
staff salaries.
Regardless of the associations scope or focus, pharmacists must be responsive to the needs and desires of the
membership served. Each association employee is ultimately responsible to the members and prospective members for whom the association exists. The membership at
large is generally represented by an elected governing
board (Board of Directors, Board of Regents, Board of
Trustees), and sometimes a house of delegates. Typically,
the activities of the association are guided through a strategic planning process, which sets the direction for the
association for the next few years.

c
Several paths exist for entry into a career with a professional association. Many association executives have
had an earlier career as a practicing member of their
profession. They have worked in the trenches for a

Encyclopedia of Clinical Pharmacy

DOI: 10.1081E-ECP 120006264
Copyright C 2003 by Marcel Dekker, Inc. All rights reserved.

Professional Associations, Clinical Pharmacy Careers in

Table I

819

Programmatic and management positions within professional associations

Position title(s)

Major responsibilities

Examples of primary focus

Association Foundation
Executive, Director of
Research Institute

Leads the not-for-profit,

charitable arm of
the association.

Research training and grants programs;

professionwide research; fund-raising.

Attorney

Legal counsel
for association.

Resource for staff, board, and officers in

matters of nonprofit or antitrust law; personnel
and copyright issues; legal disputes.

Chapter Relations.
Manager of

Primary association liaison

with chapters.

Programs and services for chapters

and other affiliates.

Chief Executive
Officer, Executive
Director, Executive
Vice President

Oversees all aspects of the

association; reports to the
elected governance of
the association.

Strategic direction; the big picture.

ComputerM anagement
Information Systems,
Manager of

Computer support systems.

Database development; membership

database management; web site
development and maintenance.

Deputy Chief Executive,

Associate Executive Director

Responsible for major

projects; often works
with personnel issues.

Specific projects of importance

to the association.

Education,
DirectorNice President
or Manager

Development and delivery

of educational programming,
including certificate programs
and other training programs.

Scientific abstracts; meeting standards

for continuing pharmaceutical education;
development of program content; working
with speakers: delivery of live, printed,
and online programming; educational grants.

Finance, Director
of/Controller

Oversees financial
management of
the association.

Accounting; management of short-,

intermediate-, and long-term investments;
financial reporting to chief executive officer
and governing board.

Government Relations
(often paired with
Professional Affairs),
Directormice President of

Leads associations
advocacy efforts to
government, legislative,
and regulatory bodies.

Lobbying; tracking legislative initiatives

to alert membership of important issues;
writing suggested legislation; interaction
with representatives of government bodies.

Human Resources,
Manager of

Personnel management.

Hiring and firing; employee policies;

employee benefits.

Marketing,
DirectorNice President
or Manager

Promotion of the association.

Promotion of membership, meetings,

publications.

Meetings and
Expositions,
Directormice President
or Manager

Planning for conventions

of the association.

Meeting logistics; site selection;

audiovisual requirements; exhibits
program; vendor contracts.

Member Services,
Directormice President
or Manager

Membership recruitment
and retention.

Dues notices; recruitment of new members;

services for members; promotional materials;
member complaints.

Professional Affairs
(often paired with
Government Relations),
Directormice President

Primary contact with other

professional associations.

Development of professional policies; attends

meetings of other related associations;
offers comment on behalf of association
regarding position statements of other
associations; collaboration with other
associations regarding mutual interests.
(Continued)

820

Professional Associations, Clinical Pharmacy Careers in

Table 1 Programmatic and management positions within professional associations (Continued)

~~

Position title@)

Major responsibilities

~~

~~~

Examples of primary focus

Public Relations Director/

Vice President or Manager

Image of the association to

the rest of the world.

Press releases; quotations for publication;

official voice of the association.

Publications
DirectorNice President
or ManagerEditor

Printed and online publications

to meet needs of membership.

Official journal; books; home study

programs; newsletters.

number of years, and were active in the association as a

volunteer, through committee work, attendance at meetings, presentation of scientific abstracts, or elected office,
By becoming known as a reliable volunteer, they set the
stage for movement into association employment. This
path is advantageous in providing the association with an
employee whom they know and who understands the
membership and the profession. However, a disadvantage
of this path is that clinical pharmacists have rarely received the management training and experience necessary
for association work.
Others who identify association work as their career
objective early in their training may enter this type of
work through summer internships, experiential clerkships
and externships, and executive residencies, or by accepting their first postgraduate job with an association and
then advancing though various positions and departments.
Many of these opportunities are listed in a document
prepared by the member organizations of the Interorganizational Council on Student Affairs.[31
Regardless of the career path chosen, preparation for a
career in association management should ideally include
several elements. Exposure to association work can be
obtained through an internship, a clerkship, or an executive residency. These experiential activities provide excellent opportunities for exposure to what it might be
like to work for an association.
Experience as a practicing member of the profession
can be an excellent way to prepare for association work.
Through spending time in actual patient care, research,
and teaching, prospective association pharmacists can
learn firsthand what members do and what their struggles
are. Furthermore, by becoming involved with associations
on a volunteer basis, it is possible to experience how the
association works. Volunteering also provides an opportunity to showcase an applicants talents and dependability to the association. Choosing to work for employers
who will allow time and support for association work is
also beneficial.
Other areas of preparation that are very helpful involve
skills aside from those taught in traditional pharmacy

curricula. Those thinking of careers in associations should

keep their eyes open to issues and events, the actions of
other related groups, and the opinions of colleagues. They
need to pay attention to the business and the politics of the
profession and be informed about them.
Finally, training in how to manage projects, people,
and finances can be very helpful for association managers.
Many of the skills necessary to be an excellent clinical
pharmacist are opposite those required to be an excellent
manager. Training and experience in this area are crucial
to excelling in an association career.

ENEFITS
There are many benefits of association work. Working
within an association provides increased opportunities to
be involved with the discipline of clinical pharmacy. For
someone who has practiced patient care, conducted research, or taught, this can provide an exciting new direction with new challenges and new skills to learn. Those
who have been members of the association before working for it often appreciate the opportunity to work for a
group having a mission they believe in and from which
they have benefited as a member.
Association work necessarily involves communication
with its members. Those working in this field have many
more acquaintances among their peers and with representatives of the pharmaceutical industry. Establishing
and maintaining contacts is an important part of this work.
Those who enjoy interacting with people will especially
enjoy this aspect of association life.
A clinical career within an association can be an opportunity for continued learning and professional growth.
Association managers often need to enhance their skills
in business management, public relations, marketing, project management, advocacy, politics, personnel management, legal issues, and many other areas, depending on
the scope of their responsibilities. Adopting the attitude
of a lifelong learner is essential, as the profession and
the world change rapidly. It is necessary to constantly

Professional Associations, Clinical Pharmacy Careers in

learn new knowledge and skills to keep up with these

rapid changes.
Working for an association opens many career opportunities in related fields, with other associations, with the
pharmaceutical industry, in other management jobs, and
in private consulting. The skills gained through association work are widely transferable to other professions, as
well as back to clinical practice.
Clinical pharmacists within associations have many
opportunities to work on new projects pertaining to the
membership and the profession. They can be creative not
only in developing a project, but also in funding, implementing, and promoting it. Association work provides a
wide variety of opportunities to practice clinical pharmacy in ways that, although different from traditional
roles, affect patient care and the profession.
Many of the knowledge and skills taught in clinical
pharmacy curricula are applicable to association work. For
example, those working with educational programs often
draw on their pharmacy backgrounds to help members
design better educational offerings. Also, research techniques learned in academic training are applicable to association research.
Perhaps the greatest benefit of association work is the
ability to represent the associations members, seeking to
improve their practices and opportunities, and to make a
difference in the profession.

TI
Those choosing to practice clinically within a professional association must have excellent organizational and
time management skills. They will experience many pressures from various directions and must be skilled at prioritizing their activities. Excellent written and verbal communications skills are also essential.
Association executives must find a balance between
being a member of the association and serving on the
staff. An attitude of servanthood is absolutely essential. It
is also critical to find a balance between listening to members and responding to their needs versus taking the lead
and establishing the direction of the association. The most
responsive associations are typically member driven,
meaning that the association staff take their lead from
the elected officers of the organization, with a focus on
implementing, rather than establishing policy.

823

When working with speakers, authors, and committees, who by definition are performing volunteer work,
association executives must be prepared to help members
meet their deadlines, through reminders, clear communication, and advance planning. Missed deadlines by members have the potential to result in periods of great stress
for association staff who in turn have printing or other
deadlines that cannot be changed. As this can be a source
of great stress, it is essential to have the personal fortitude
to deal with the unexpected and uncontrollable.
Because associations must function as businesses,
serving as stewards of their members resources, there is
less freedom for association employees to function as
independently as they might in an academic environment.
Budgets must be developed and adhered to, and performance targets established and met. Also, because the
elected officers change regularly, the direction of the
association and the style of the governing board can
change frequently. Clinical pharmacists working within
associations must be flexible, as issues and responses
can change, may not always agree with their personal
opinions, and are often outside their control.

c
Working as a pharmacist within a professional association is a challenging, yet rewarding way to practice
clinical pharmacy. This career choice should be strongly
considered by those who seek to serve their colleagues and
the profession by helping them manage and adapt to everchanging issues in clinical pharmacy.

EFERE
1. Casteuble, T. What todays association executives earn.
Assoc. Manage. 1997, 49 (4),53-61.
2. American Association of Colleges of Pharmacy. 19992000 Profile of Pharmacy Faculty. In Institutional Research Report Series; American Association of Colleges of
Pharmacy: Alexandria, Virginia, 1999.
3. Interorganizational Council on Student Affairs. Znterorganizational, Financial, and Experiential Information Document; Interorganizational Council on Student Affairs,
American Pharmaceutical Association: Washington, DC,
2000.

PROFESSIONAL DEVELOPMENT

Julie A. Dopheide
University of Southern California, Los Angeles, California, U.S.A.

Psychiatric pharmacy practice is a rewarding specialty

with diverse opportunities to have an impact on the care
of patients directly through innovative practice models,
quality assurance, and patient education, and indirectly
through professional education, the development of
treatment guidelines, clinical research, and careers in
the pharmaceutical industry.['-31
Psychiatric illness occurs in 50% of the population
over the course of a lifetime and nearly 30% over the
course of a year.[41 It affects all age groups and causes
significant morbidity, mortality, and diminished quality
of
Medication management is essential to treat
acute symptoms of psychiatric illness and to prevent
relapse. In fact, psychotropic drugs (antidepressants, antipsychotics, anxiolytics, hypnotics mood stabilizers, stimulants) comprised 10% of the top 200 brand name and
generic drugs dispensed from retail pharmacies in the
year 2001.[~]
Similar to other specialty practice areas, psychiatric
pharmacy requires core knowledge of disease state management and the ability to demonstrate clinical skills in
applying knowledge to improve patient care. A distinguishing aspect of psychiatric pharmacy is the requirement that the practitioner have an interest and aptitude
for interpersonal communication and developing professional relationships. Patient evaluation and drug therapy
assessment is based on an interview that uses mental
status examination, as well as standardized psychiatric
rating scales, to assess symptoms and adverse effects.
Clinical service involves collaboration with physicians,
nurses, social workers, psychologists, and other health
care professiona~s.["~~
A specialized residency is ideal to prepare a pharmacist
for a career in psychiatric pharmacy practice. There are
approximately 25 to 30 1-year, post-PharmD residencies
in psychiatric pharmacy practice across the United States,
with 17 receiving accreditation by the American Society

822

of Health-System Pharmacists (ASHP).[781 Each residency may offer a unique feature such as an ambulatory
care focus or teaching skills development; however, the
emphasis of residency training is on specialized clinical
knowledge and skill development.[']
Given the high prevalence of psychiatric illness and
specialized expertise required for successful pharmacy
practice, it makes sense that psychiatric pharmacy has
become one of the five specialty practice areas certified
by the U.S. Board of Pharmaceutical Specialties. As of
December 2001, there were 387 certified psychiatric
pharmacy specialists."'] The certification process started
in 1990, when a coalition of educators and practitioners
identified a need to define the specialized knowledge and
skills required to function as a competent psychiatric
pharmacy specialistL2]The coalition's petition was sponsored by the ASHP and the first examination took place
in December 1996.
This article presents opportunities in psychiatric pharmacy, provides examples of model practice settings, discusses the impact of psychiatric pharmacy on health outcomes, reviews the tools used by specialty practitioners,
and discusses networking opportunities in psychiatric
pharmacy specialty practice.

Opportunities in psychiatric pharmacy continue to expand with specialists practicing in hospitals, clinics, longterm care facilities, developmentally disabled centers,
prisons, academia, and the pharmaceutical i n d ~ s t r y . " , ~ ]
Although acute care facilities exist to treat the most severely ill patients, primary care clinics provide service
for the majority of patients. Model practice settings
exist for both acute and primary care. and are discussed
later in this article. Other opportunities are discussed in
this section.

Encjclopedia oj Clinical Pharmacy

DOI: 10.1081E-ECP 120006238
Copyright 0 2003 by Marcel Dekker, Inc. All rights reserved.

Psychiatric Pharmacy Specialty Practice

It is estimated that 25--50% of patients in long-term

care facilities suffer from neuropsychiatric disorders that
are functionally impairing.'"] At least 26% of incarcerated adults"21 and 52% of children in the juvenile justice
system meet criteria for a DSM-IV-TR disorder.[13] When
substance abuseldependency is included in the adult population, the incidence rises to 7 1%.[12] Psychiatric pharmacist specialists can provide consultation on optimizing
drug therapy for patients in these settings.
Half of the homeless suffer from mental illness, and
rely on community outreach, missions, and governmentrun clinics to provide service.[143151
A psychiatric pharmacist is uniquely qualified to manage the coordination of
medication follow-up for these patients. Developmentally
disabled individuals are often treated for a combination of
neurologic and psychiatric problems and, therefore, have
unique drug interaction considerations and communication obstacles. Psychiatric pharmacists currently serve as
consultants and members of multidisciplinary treatment
teams to optimize the care of these
Quality of care for individuals with psychiatric illness
has come under scrutiny with several studies documenting
a need for improvement in medication management.['7-191
Psychiatric pharmacists have the opportunity to improve
care through quality assurance surveysldrug-use evaluations, patient and staff e d u c a t i ~ n , [ ~and
. ~ ~ direct
I
medication management."] Psychiatric pharmacist specialists
are an important community resource for consumer advocacy groups such as NAMI, also known as the National
Alliance for the Mentally
In addition, psychiatric pharmacists have opportunities
for involvement in treatment guideline development for
psychiatric disorders. The American Pharmaceutical
Association recruited psychiatric pharmacy specialists to
develop their guidelines for psychiatric disease state
management. [221
Dr. Lynn Crismon's work in developing the Texas
Medication Algorithms for treatment of depression in
children and adults and the treatment of attention-deficit hyperactivity disorder in ~ h i l d r e n ' ~ , laid
~ ~ , ~the
~]
groundwork for psychiatric pharmacists to work with
psychiatrists, psychologists, other health care professionals, and consumer groups to develop and implement
national therapeutic guidelines.

An attractive feature of psychiatric pharmacy is that it

offers creativity in developing a practice that is individualized to the setting and patient population of interest to

823

the practitioner. Model practice settings in hospitals and

several clinics are discussed in the following paragraphs.

Hospital
Psychiatric pharmacy specialists in hospitals provide a
wide range of services, including participation in multidisciplinary treatment planning, medication education
groups for patients, therapeutic drug monitoring, discharge counseling, and quality a s ~ u r a n c e .201
' ~ Model
practices exist across the United States for the acute care
psychiatric pharmacist; however, the scope of practice is
variable based on staffing, institutional support. and interest of the practitioner. Through the years, a patientfocused model has evolved using the principles of pharmaceutical care whereby the pharmacist develops a
professional relationship with the patient in addition to
staff and takes responsibility for health outcomes.
Psychiatric pharmacy in the acute care setting involves
patient interviews for initial assessment and follow-up
monitoring. The pharmacist obtains a medication history
to facilitate treatment plan development, in addition to
participating in multidisciplinary rounds for exchange of
information and therapeutic decision making. The inpatient psychiatric pharmacist conducts therapeutic druglevel monitoring of lithium and anticonvulsants. Conducting medication education groups and individual
medication counseling sessions are standard functions of
the inpatient psychiatric pharmacist.[251

Primary Care
In the primary care setting, there are several practice
models for pharmacy-run clinics. Typically, patients are
evaluated by a psychiatrist and referred to the psychiatric
pharmacist for medication management and ongoing
assessment.[261The Veteran's Administration (VA) health
care system was one of the first to use psychiatric pharmacy specialists in mental hygiene clinics in the 1970s.
Currently, the VA health care system supports psychiatric
pharmacist specialist involvement in several psychiatric
clinics, including the cognitive disorders, mood disorders, psychiatry emergency, geropsychiatry, and clozapine ~ l i n i c s . [ ~ ~ , ~ ~ ]
Extent of involvement varies across VA systems. For
example, at the VA clinic in La Jolla, California, a
psychiatric pharmacist's scope of practice includes: 1)
assessing clinical response to medication via mental status
exam and psychiatric interviewing techniques; 2 ) assessing development of adverse drug reactions; 3) ordering
and evaluating appropriate laboratory tests to assess cli-

Psychiatric Pharmacy Specialty Practice

824

nical response, assess development of adverse drug reactions, and evaluate therapeutic drug levels; 4) making
changes in psychotropic drug therapy using the physician
order form or through direct order entry into the computer; 5) assessing patient compliance with medications
by analyzing computer dispensing records and quantities
of medications dispensed versus doses remaining; 6)
documenting findings, actions, and plans in the patients
medical records on the progress notes form or through
direct progress note entry into the computer; 7) providing
prescriptions for all medications with enough medications
to last until the patients next appointment; 8) providing
patient medication education, including methods of
coping with certain side effects, recognizing symptoms
of toxicity, and emphasizing the importance of compliance, and when appropriate, providing written information; and 9) rescheduling patients for follow-up appointments with an appropriate clinician. In a VA clinic in
Waco, TX, a psychiatric pharmacist specialist has similar
scope of practice but is assessed quarterly, in writing, by
the supervising psychiatrist.
Scott and White hospital in Texas is an example of
a pharmacy-run womens health clinic. In this model,
the obstetrics-gynecology physician or nurse identifies
patients at risk for mood disorders, including premenstrual syndrome and premenstrual dysphoric disorder, and
refers them to the pharmacist for further evaluation, treatment, and drug therapy monitoring. Patient approval ratings were 96% excellent.[291

based on decreased clinic visits and decreased prescriptions of $22,241.25 over 3 months.[301
One prospective study from Australia analyzed clinical
pharmacy interventions on an inpatient psychiatric unit
over a 6-month period. Two hundred and four interventions were proposed for 69 patients, 91.7% of which
were accepted. Some of the interventions (20.3%) were
estimated to be of major clinical significance, with added
cost savings of 24,700 based on cutting 38 days of inpatient care at $ 6 5 0 / d a ~ . [ ~ ~ I

TOOLS
Psychotropic drug therapy expertise, interview technique,
and the mental status exam are the most used tools of
the psychiatric pharmacist. Validated psychiatric rating
scales are also used and allow objective measurement of
drug therapy outcomes. Psychiatric pharmacists develop
expertise in using standardized rating scales such as the
Hamilton-Depression Rating Scale and the Monitoring of
Side Effects Scale (QSES).[32,331American Psychiatric
Association rating scales and online references, such as
Clinical Pharmacology,[341are available on CD-rom and
make the information easily retrievable in settings with
computer capabilities. Clinical psychiatric pharmacists
use portable laptop or notebook computers and personal
data assistants, or PDAs, to keep track of patient profiles,
drug therapy recommendations, and outcomes.

industry
NETWORKING
Psychiatric pharmacy specialists are vigorously recruited
by industry to serve as medical science liaisons, neuroscience managers, members of advisory boards, and
resources of drug information for physicians and other
health care professionals.]

BENEFITS OF SPECIALTY PRACTICE

Several U.S. studies report improved care, improved level
of functioning, and economic savings attributed to psychiatric pharmacist intervention^;[^] however, the studies
are small, generally retrospective in nature, and most lack
rigorous controls. One chart review of 60 clinic patients
compared pharmacist prescribing with psychiatrist prescribing and determined pharmacist prescribing was as
good as or better than physician prescribing.[261 The
largest study was a chart review in some 4700 patients,
which documented that 66% of pharmacist recommendations were implemented with an extrapolated cost savings

Networking can be accomplished by participating in

national meetings where psychiatric pharmacy specialists
gather to exchange ideas, participate in neuropsychiatric
educational programming, and discuss professional issues
such as residency training, reimbursement, and health
care policy. These national meetings include the College
of Psychiatric and Neurologic Pharmacists,] ASHPs
Section of Clinical Specialists in Psychiatric and Neurologic Pharmacy,[71and the American College of Clinical
Pharmacys (ACCP s) central nervous system practicerelated network.[351 The psypharm listserv has approximately 400 participants (George Foose, personal
communication) and is an effective tool for rapid-response networking with national and international psychiatric pharmacists. To become a member of psypharm
and/or of the College of Psychiatric and Neurologic
Pharmacists (CPNP) listserv, log on to the CPNP web site
or contact Dr. George Foose via e-mail at gfoose@msn.
Com.[s,361

Psychiatric Pharmacy Specialty Practice

Psychiatric pharmacy is an internationally recognized

specialty, with organized representation in Canada, the
United Kingdom, Scotland, and the Netherlands. The
United Kingdom Psychiatric Pharmacy Group has its own
web site,[371 and offers a postgraduate certificate in
psychiatric pharmacy for practitioners in Great Britain
and other countries. Currently, certification is ongoing for
practitioners in Hong Kong, Canada, and New Zealand.
The Scottish organization is known as The Scottish
Pharmacists in Mental Health. The Dutch Association of
Hospital Pharmacists has a special interest group in the
field of psychiatry, with goals to elevate psychiatric
pharmacy practice to include pharmaceutical care and
therapeutic drug monitoring, in addition to distributive
services. Practitioners from the United Kingdom and
Canada report practice activities that are similar to U S .
psychiatric pharmacists with regard to multidisciplinary
treatment planning, patient and staff education, and
quality assurance.

EFE
1. Cohen, L.J. The role of neuropsychiatric pharmacists. J.
Clin. Psychiatry 1999, 60 (Suppl. 19); 54-58.
2. Crismon, M.L.; Fankhauser, M.P.; Hinkle, G.H.; Jann,
M.W.; Juni, H.; Love, R.C.; Ray, M.D.; Stimmel, G.L.;
Wells, B.G. Psychiatric pharmacy practice specialty certification process. Am. J. Health-Syst. Pharm. 1998, 55
(15), 1594- 1598.
3. Jenkins, M.H.; Bond, C.A. The impact of clinical pharmacists on psychiatric patients. Pharmacotherapy 1996. 16
(4);7-8-714.
4. Kessler, R.C.; McGonagle, K.A.; Zhao, S.; Nelson, C.B.;
Hughes, M.; Eshleman, S.; Wittchen, H.U.; Kendler, K.S.
Lifetime and 12-month prevalence of DSM-111-R psychiatric disorders in the United States. Results from the
national comorbidity survey. Arch. Gen. Psychiatry 1994,
51 (l)? 8-19.
5 . Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition, Text Revised; American Psychiatric Association, APA Press; 2000; copyright 2000.
6. Top 200 Drugs of 2001 as Published in Drug Topics;
www.drugtopics.com (accessed March 4, 2002).
7. American Societ)i of Health System Pharmacists (ASHP)
Residency Directoiy; The ASHP website at www.ashp.org
(accessed July 2001).
8. College of Psychiatric and Neurologic Pharmacists
(CPNP). www.cpnp.org (accessed July 2001).
9. ASHP Residency standards for psychiatric pharmacy practice. ASHPs Residency Directory 2001, (2), 237-245.

825

10. Board of Pharmaceutical Specialties (BPS) Pharmacy

Specialization Newsletter; American Pharmaceutical Association (APhA), December 2001: 11 (3).
11. Furniss, L.; Burns, A,; Craig, S.K.L.; Scobie, S.; Cooke, J.;
Faragher, B. Effects of a pharmacists medication review
in nursing homes: Randomised controlled trial. Br. J.
Psychiatry 2000, (176): 563-567.
12. Birmingham, L.; Mason, D.; Grubin. D. Prevalence of
mental disorder in remand prisoners: Consecutive case
study. BMJ 1996, 313 (7071), 1521-1524.
13. Garland, A.F.: Hough, R.L.; McCabe, K.M.; May, Yeh.;
Wood, P.A.; Aarons, G.A. Prevalence of psychiatric disorders in youths across five sectors of care. J. Am. Acad.
Child Adolesc. Psych. 2001, 40 (4);409-412.
14. Tolomiczenko, G.S.; Goering, P.N.; Durbin, J.F. Educating the public about mental illness and homelessness: A
cautionary note. Can. J. Psychiatry 2001, 46 (3), 253257.
15. Hotchkiss. B.D.; Pearson, C.; Lisitano, R. Pharmacy coordination of an indigent care program in a psychiatric
facility. Am. J. Health-Syst. Pharm. 1998, 55 (12), 12931296.
16. Berchou, R.C. Effect of a consultant pharmacist on medication use in an institution for the mentally retarded. Am.
J. Health-Syst. Pharm. 1982, 39, 1671 - 1674.
17. Young, A.S.; Sullivan, G.; Bumam, A,: Brook. R.H.
Measuring the quality of outpatient treatment for schizophrenia. Arch. Gen. Psychiatry 1998, 55, 61 1-617.
18. Lehman, A.F.; Steinwachs, D.M. Translating research into
practice: The schizophrenia patient outcomes research
team treatment recommendations. Schizophr. Bull. 1998,
24, 1-10,
19. McCombs, J.S.; Nichol, M.B.; Stimmel, G.L.; Shi. J.;
Smith, R.R. Use patterns for antipsychotic medications in
medicaid patients with schizophrenia. J. Clin. Psychiatry
1999, 60 (Suppl. 19), 5-11.
20. Moebius, R.E.; Jones, B.B.; Liberman, R.P. Improving
pharmacotherapy in a psychiatric hospital. Psychiatr. Serv.
1999, 50 (3), 335-338.
21. Finley, P. Ask your Psychopharmacist. In NAMI, Advocate; NAMI: Arlington, Virginia, Winter 2002.
22. Treatment Guidelines for Schizophrenia. Major Depression, Bipolar Illness, Panic Disorder, Generalized Anxiety Disorder, Obsessive Comnpulsive Disorder and
Social Anxiety Disorder; American Pharmaceutical Association Publications: Bethesda, Maryland, copyright
1998-2000.
23, Hughes, C.W.; Emslie, G.J.; Crismon, M.L. The Texas
childrens medication algorithm project: Report of the
Texas consensus conference panel on medication treatment
of childhood major depressive disorder. J. Am. Acad.
Child Adolesc. Psych. 1999, 38 (5), 517-528.
24 Plizska, S.R.: Greenhill, L.L.; Crismon, M.L. The Texas
childrens medication algorithm project: Report of the
Texas Consensus conference panel on medication treatment of childhood attention-deficit/hyperactivity disorder

826

25.

26.

27.

28.

29.

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Parts I and 11. .I.Am. Acad. Child Adolesc. Psych. 2000,

39 (7), 908-927.
Stimnicl, G.L.; Wincor, M.Z. Mental Health Pharmacy. In
Handbook qf lnstilutional Phurrnacy Pructice, 2nd Ed.;
Smith, M.C., Brown, T.R., Eds.; Williams & Wilkins
Co.: Baltimore, 1986; 535-- 544.
Stimmel, G.L.; McGhan, W.F.; Wincor, M.Z. Comparison of pharmacist and physician prescribing for psychiatric inpatients. Am. J. Hosp. Pharm. 1982, 39, 1483
1486.
Defilippi, J.L. Perronal Communication on Approvc.rl
Scope of Psychiatric Pharmacy Pructice in the Veterans
Administration Mental Hygiene Clinic, Waco, Texas; May
2001.
Dishman, B. Personal Communication on Approved Scope
of Practice for Psychiatric Clinical Pharmacy Specialist at
the Veteruns Administration Healthcare system, La Jollu,
Calf(irnia; J ~ l y200 1 .
Jermain, D.M.; Sulak, P.J.; Woodward, B.W.; Knight,
A.C. Psychopharmacy medication clinic in a managed care

30.

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32.

33.
34.
35.
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womens health setting. Am. J. Health-Syst. Pharm. 1997,

54 (23), 2717 2718.
Lobcck, F.; Traxlcr, W.T.; Bobiner, D.D. The costeffectiveness of a clinical pharmacy scrvice in an outpatient mental health clinic. Hosp. Commun. Psychiatry
1989, 40, 643 644.
Alderman, C.P. A prospective analysis of clinical pharmacy interventions on an acute psychiatric inpatient unit.
I . Clin. Pharm. Ther. 1997, 22 (l), 27-31.
Sajatovic, M.; Ramirez, L.F. Rating Scales in Mental
Health; Lexi-comp Inc.: Hudson, Ohio, 2001, copyright
200 1.
American Psychiatric Association ( M A ) Rating Scales;
2000, copyright 2000.
Clinical Pharmacology; www.clinicalpharmacology.com.
American College of Clinical Pharmacy (ACCP). www.
accp.org.
Psypharm listserv. [email protected].
United Kingdom Psychiatric Pharmacy Group (UKPPC).
www.ukppg.org.uk (accessed July 2001).

PROFESSIONAL DEVELOPMENT

Fundacion Hospital-Asil de Granollers, Granollers, Spain

IMT

TI

Here, we outline two basic questions:

Organizations exist as long as they are able to produce

services that are of interest to someone-this someone
being customers. Pharmacists create small organizations
(e.g., hospital pharmacy services, community pharmacies,
ambulatory settings) that are located within other organizations (e.g., hospitals, primary care, home care),
which in turn are integrated into what we may consider
the healthcare system organization.
The final customers of the healthcare service are
patients and their families, and the final product is health.
Health as a product is not easy to define and measure. A
way to measure the product of healthcare systems is to
look at their outcomes. Today, the outcomes of healthcare
systems are considered to be economic, clinical, and
humanistic in nature.
Pharmacists participate in the healthcare system and in
its final product. Sometimes they directly access the
patient, and other times, they indirectly access the patient
through other health professionals (doctors, nurses),
providing them with what belongs to us-our knowledge
of drugs. Drugs are widely used as resources in all
healthcare systems. Our objective would be to achieve a
safer and effective medication-use process.
However, the healthcare system is only furnished with
limited resources, facing endless new technologies and
growing service demand by the population. All this
translates into tremendous economic pressure on healthcare professionals.
This is the starting point in the development of the
subject of quality assurance in pharmacy services.

LlTV
There are many definitions of quality;"331 however, we
reduce the concept to the bare bones. That is, quality is
doing things right, or better said, allowing our customers
to receive good service because they, precisely, are the
ones who rate the quality of the service (Fig. 1).

Encyclopedia of Clinical Pharmacy

DOI: 10.1081E-ECP 120006379
Copyright 0 2003 by Marcel Dekker, Inc. All rights reserved.

1. Who are the customers of the pharmacy service?

Patients, their relatives, physicians, nurses, society,
managers and administrators, politicians, students,
and so on are the customers. They do not always
share the same values and can even have conflicting interests. This is due to agency relationships, so frequent in healthcare.
2 . Which are the services offered by the pharmacy
service? This question does not refer to what
pharmacists do, how they invest their time, or
what their tasks are-all that is well known. We
know what is done, but it is more difficult to
prove what it is for; that is, what is the usefulness for the patient? The question refers to what
clients receive from pharmacy services, from their
own point of view. As stated previously, what
customers get is what makes sense to pharmaceutical organizations.
It is strategic for clinical pharmacy services to identify
and segment customers to meet their expectancies and
needs. It results in good customer management.
As a profession, the services we offer are not fully
agreed upon or conceptualized, but delivery of medications, and manufacture and handling, are. These services
are our baseline services. It is far more difficult to
consensuate and conceptualize the pharmacists' cognitive
services and their added value to health process, yet there
have been some attempts.[u1 The reason is likely to be
that we are not paid to do that,[71 so we do not feel
obligated to do so, unlike other professions with a great
knowledge load.
We should find a way to accomplish it and offer a
portfolio of services. This portfolio of pharmaceutical
services should be patient oriented and customer focused.
There are some works in the literature that describe the
needs assessment with different customers (patients,
healthcare teams, et~.).[~-"]

827

uality Assurance of Clinical Pharmacy Practice

828

ECONOMICAL

HUMANISTIC

PHYSICIAN
NURSE
PATIENT
ADMINISTRATORS
THIRD-PARTY-PAYERS
STUDENTS
SOCIETY

PHYSIC1.4N
PATIEUT
ADMINISTRATORS
THIRD-PARTY-PAYERS
STUDEYTS
SOCIETY

Fig. P

Rating quality of service

The next step is to define what the characteristics are

of each service we offer in this portfolio. By these
characteristics, we are defining the variables of quality
itself. Quality would also include, besides technical
aspects, those aspects related to communication skills,
which are quite valued in customer satisfaction. The
cognitive, behavioral, and emotional aspects of communication are thus considered.
In working toward quality, there are several steps and
different tools:
e
a
0

Certification.
Accreditation.
Self-evaluation.

Certificati
The object of certification is to ensure that what is done is
what was said would be done. In certification, we normalize both processes and procedures. A process is a
sequence of activities performed to provide a service. The
activity is what is done, whereas a procedure is the
documentation that describes how to perform a process (a
set of activities). A service is what the patient gets, and
the outcome is the result of the service.
To provide our customers with these services, we are
furnished with material and human resources that produce

them. The production of services takes place by means of

processes (Fig. 2). To obtain high-quality services,
processes need to be very well defined, and to be known
and accepted by those performing them. A good way to
define them is using flowcharts.
Quality should never be improvised; quality is
planned. Service production processes should be well
defined. Those performing them should known them, and
be well prepared and trained for this objective of quality.
People want to work properly, so organizations should
prepare the ground, clearly stating what it is expected
from them, training them adequately, and commending
that is done well.
In this normalization of processes, the activities to be
performed should be defined, as well as their sequence
and who does it and h o ~ . " ~ This
. ' ~ ~is a good time to
incorporate technologies such as information system,
robotics, communication systems, and so
In the definition stage of this process, it is essential to
be flexible, to have an open and imaginative mind, and to
question everything-what is done, why, for what reason,
and for whom (in these steps, some tasks are often found
to be unnecessary and can be left undone because they
provide nothing to the final service or are repeated; some
activities are done just because it has always been that
way). It is good to have a variety of people with different
points of view, and it is advisable that the staff involved
in the process also participate in it, whatever their train-

Quality Assurance of Clinical Pharmacy Practice

829

ECONOMICAL

OUTCOME
HUMANISTIC

NEEDS

PRODUCTION
PROCESSES
Fig. 2 Production of service by means of a process.

ing, because they are the ones who know their work best
and know how to improve it. It has the advantage of
facilitating empowerment, homogenizing criteria, and
forcing the culture of quality to develop.
Once the process is defined, it simply has to be
performed as described. The objective of this is to avoid
variability in its execution and thus in its quality, depending on the person who performs it.
Everything should be normalized: process controls,
equipment servicing, staff training, quality control (few
indicators on critical points), frequency of the process
review, and definition of responsibilities. The documentation of these activities should also be
Processes normalization is distinct in each organization, because each organization is unique. This should be
the second step toward quality. Defining our customers
and our service portfolio is the first step. Each service
should have a well-defined and normalized elaboration
process, with a clear beginning and end.
So far we have discussed the operative processes-that
is, the service production processes-but there are other
equally relevant processes, such as support services (not
perceived by the customer, but also essential, e.g.,
maintenance, purchases, etc.) and strategic services (they
orient the whole organization; Fig. 3). The quality of all
these processes is susceptible to evaluation.

Accreditation
Although certification ensures the homogeneity in the
quality of organizations, accreditation is based on the
creation of quality standards in service quality and in the
comparison among several organization^."^.^^^ Accreditation is granted by external organizations, which set the
criteria and standards that are used as indicators of health.
Before undergoing external accreditation. it is essential to
know the requirements and to specifically prepare for
them. An external accreditation is an acknowledgmenr
that the quality requirements established by that organization are fulfilled. Actually, quality is predefined by
means of indicators and standards. Accreditations may
include structure, processes, and results standards. The
current trend is toward the assessment of results,
whenever possible.

Self-Evaluation
In self-evaluation, organizations enter a constant circle
of questioning what they are doing. how, for whom, and
how they can improve it. It involves an important degree
of dynamism and maturity throughout the organization.
with a clear, decided focus on the customer and society.
It is a path toward excellence: the continuous culture of

Quality Assurance of Clinical Pharmacy Practice

830

ECONOMICAL

OUTCOME

er

i
I
IIWOVATION

~~~~~~~~

CLINICAL
HUMANISTIC

Strategic Processes
MAhAGEMENT

MANAGEMENT

MANAGEMENT

n
I

COMMUNICATION

PRODUCTION
PROCESSES
WefativeProd&s&3

MAINTENANCE

PURCHASES

11

I
SERVICES

INFORMATION
SYSTEM

Support Processes
Fig. 3 Strategic, operative, and support processes.

quality. Their common feature is a proactive approach to

quality. It deals with double-checking that what the
organization designs is what customers really want and
need, and if that it is precisely what the organization is
actually providing.
At this level, we introduce concepts that are in vogue
such as benchmarking and innovation. Both look for
improvements in services and/or processes. The first concept does so by searching for better ways of working in
other organizations; the second concept does so by means
of imagination and creativity.
Benchmarking was first introduced in business science
as an efficient and effective way of optimizing companies. It deals with looking for practices that proved
successful in other companies, and implementing them
into ones own company, or in plain words, copying the
best one^.[^^-'^]
Innovation is the key to the future. It means to be alert
as to how society, the healthcare system, and the macroand micro-context in which we live, will evolve. An

example of adaptation to the environment is the very

concept of pharmaceutical care meant a great innovation
for the profession,[251 and the contribution of the
pharmacist in the detection and prevention of therapeutical errors, designing specific programs for it.[269271
In the healthcare sector, innovation is closely related to
research and scientific evidence. We should increase our
research on quality and also make it b e t t e ~ - . [ ~ Then,
- ~ ~ ] it
has to be published and d i ~ s e m i n a t e d . This
~ ~ ] should be
done with high scientific level works, producing scientific
evidence of quality. The study question should be less
how am I doing it? (pharmacist oriented) and more
how do I improve the care offered to the patient?
(patient oriented).

KEY POINTS
Conceptualization and measurement are the key points.
Quality management is achieved by the management of

Quality Assurance of Clinical Pharmacy Practice

831

customers, people, and processes. It is essential to follow

a strategy because quality is not improvised. Conceptualization is what gives congruity to the whole system. In
practice, this implies the following tactic.

These services are of an intangible nature, so it is

sometimes positive to introduce elements to make invisible operations visible (e.g., to develop a physical
support allowing the customer to see it clearly). Ours is a
multidisciplinary job, and this must be reflected not only
in our research, but also in our attitude and daily work,
as full patient-focused members of the healthcare
team. [35,361

Defining the portfolio of services and the level of

quality of each service. Knowing the needs before
designing and performing the service. Besides expressed
needs (demand), we have to explore the hidden, or not
expressed, needs. We should know what services and
with what characteristics of quality are of interest to our
customers, avoiding unnecessary efforts in services that
will not be valued or that will be useless to us (although
our unit may consider them interesting). In this section,
qualitative research is a tool to consider. This is a
strategic step.

We have to be readily accessible, both in terms of

space and time. We have to leave pharmacy offices and
go to the patient and the healthcare team.[371We must
clearly and firmly lead all those activities related to drugs
because this is the knowledge field of our profession.
Leadership has a lot to do with effectively communicating
to influence others actions, attitudes, beliefs, and so on.
Pharmacy services must relocate themselves strategically
as proactive agents in the healthcare team.

issemination
Designing Process
It is important to design, or redesign the process so it fits
the needs of each service.[341Many of our pharmaceutical
services are related to the production of clinical services.
Considered with products, these services have many
special characteristics to consider:
e
0
0

They have a high content in customer care.

Their main element is the human factor.
Part of the quality of the service depends on the
customers perception.
The satisfaction of the service provider is transmitted
to the customer.
Many services waste time while being produced, and
the customer participates in its production (e.g.,
interviews with the customers). This means that the
services cannot be stored or repeated. This is the
concept of sewuction, or production of services.
Services can be personalized.
Demand is not stable and is often unpredictable.

These conditions are especially met by services related

to knowledge. This is why the human factor is so important in the quality of pharmaceutical services with high
added value. It is essential to reach an agreement on
criteria, continuous education, and documentation. The
degree of outcomes we observe in our patients depends in
great measure on this quality. Human quality potenciate
the technical quality.

Disseminate by notifying the customer about our work,

and any improvement of it (marketing). Pharmaceutical
services should notify the value of the processes in which
they are leaders, and it should be loud and clear.
Due to its very nature, the work of pharmacists is
multidisciplinary, as they are full, patient-focused members of the healthcare team.[38,391To the patient, integration of the different areas or specialists who provide care
is desirable. It is also true for the healthcare system. It is
fundamental, of course, not only to have extensive clinical and drug knowledge, but also communication,
negotiation, and leadership skills, as well as specific
training in clinical interviews, pertaining to the customer
and to the specific situation within the exercise of the
profession. The best way to make ourselves known is
with our daily work. It is then that we should let the
healthcare staff know it, participating in other professions forums, in consumers associations, teaching other
professionals, and using different channels, including
mass media.
A multidisciplinary team works in coordination,
sharing both patients and responsibility, both in the
patients direct care and in planning such care. Quality is defined in care planning, such as clinical sessions, elaboration, implementation, follow-up and
evaluation of protocols, clinical paths and clinical
guidelines, participation in different clinical commissions, and so on. Clinical pharmacists must be recognized as leaders in all drug-related aspects. It is not a
right, it must be earned.

832

Quality Assurance of Clinical Pharmacy Practice

In an automated, natural manner, but in different

settings from the strictly pharmaceutical, clinical pharmacists integrate clinical research and publications,
together with other professionals. This involves disseminating the services that clinical pharmacy has to offer.
Actually, all healthcare professionals should learn that
the center of the healthcare system is the patient, and
rather than classifying the patients functions, what is
important are those processes that provide an added value
to the patients health, and those who lead them. It means
establishing alliances between members of the healthcare
team. Perhaps we should start viewing the members of
health teams as being coresponsible for care, and even
incorporate patients themselves into the team, with a firstline role, taking active part in decisions. The clinical
pharmacists goal is for patients to see them as an ally,
someone on whom they can rely.

service effectively fulfills its mission (considering its

three dimensions: economic, clinical, and humanistic,
along with patient satisfaction). In practice, this means to
measure. Pharmaceutical services have to be measurable
to be self-evaluated, corrected, and improved.
We can measure quality in our activities and in the
services we p r o d ~ c e , [ ~as~ well
~ ~ ]as the impact of our
contribution to the outcomes of the healthcare system in
terms of qualityr421(Fig. 4).
For economic outcomes, we can use pharmacoeconomy as the main tool.[431There is a great variety of clinical indicators that we can relate to drugs efficacy and
safety. These clinical indicators, obtained with designs
from clinical epidemiology (observational and experiare excellent to measure clinical outcomes.
To obtain indicators for humanistic outcomes, such as
satisfaction and quality of life, we have different tools,
such as surveys, and different qualitative research methods (interviews, focus groups, e t ~ . ) . [ ~ ~ ~ ~ ]
Measuring wastes some resources, and the concept
of cost-opportunity makes us cautious when tempted
to measure whatever is at hand. We should measure
little, and just what is critical (even monitoring and

easure
It is important to have a discussion with the customer after
delivering our service to ensure that, once started, this

Structure
Indicators

Indicators
Process

Services
Indicators

ECONOMIC

Economic
Indicators

PHARMACOECONOMICS

,
CLINICAL
EPIDEMIOLOGICAL
METHOD

CLINICAL

(OBSERVATIONAL &

,D
HUMANISTIC

&

QUALITATIVE
METHODS
SURVEYS

Fig. 4 Quality research.

::.

Satisfaction
Quality of life

Quality Assurance of Clinical Pharmacy Practice

measuring at a preestablished frequency) a n d o r important and significant. Before deciding to measure,

we must be sure that we are using the best indicator
as possible to reach our objective. We must know why
and for what we are measuring-it
is not the same
to obtain a certification, make a decision, or research
and publish.
The same criteria should be applied for technical
questions of internal interest and for the clinical aspects of
interest to the patient and the rest of healthcare staff. In
this case, the language should be common to the rest of
the healthcare staff, and indicators should be clinical
indicators. This information, both positive or negative,
has to be disseminated, clarified, and shared. We must
insist on the use of clinical and satisfaction indicators, as
well as of economic ones.

Quality is something one pursues in an active manner.

Once we start the path toward quality, we cannot abandon
it: it just becomes part of our daily routine.

In this article, it was our intent to present a perspective on this topic, providing different tools to
approach the quality of pharmaceutical services. These
have been placed in a context where the concepts of
limited resources, cost-opportunity, and efficacy are
implicit. The concept has been abstracted so it can be
applied to the public or private sectors, to hospital or
ambulatory settings, and to different societies, with
different values.
As for the external quality systems, we deliberately
avoided the description of official quality systems, such as
the Joint Commission on Accreditation of Healthcare
Organizations (accreditation), International Standarization Organization (certification), and European Federation
for Quality Management (self-evaluation), because it
would have been impossible to cover them all. Instead, we
abstracted the topic of quality, and all these external
quality systems will probably assume most of the things
discussed in this article.
Quality is planned and evaluated. In other words,
quality is managed; it cannot be detached from management in its broader sense. Quality management is
achieved by quality customers. people and process management. Quality varies according to the context and also

833

with time. Quality is dynamic because the environment is

dynamic. We must continuously adapt ourselves to the
environment and innovate. What now is a gold standard
will perhaps be a minimum tomorrow.
Quality is evaluated by measuring relevant indicators.
Outcomes indicators (economic, clinical, and humanistic)
will be the major importance in the future for clinical
pharmacist services. Clinical pharmacist services must
relocate themselves strategically as a proactive agent and
lead drug therapy in the healthcare team.
The challenge will be the economic evaluation of
pharmacy services. Once the products of pharmaceutical services and its outcomes are defined, considering
economic, clinical, human outcomes, and once the minimal or standard quality if the services (both basic
and value-added services, with high degree of knowledge), then we must know its
In the context
of healthcare systems, where they are currently immersed, with huge economic pressure, it is necessary to
prove that the resources used by pharmaceutical services are cost effective for the healthcare system and
the patient. In other contexts, and maybe in the future,
it will be important to price these pharmaceutical services that our patients are going to receive.r503511
By
orienting our services through quality, they will probably be more effective, because we will not incur in
the cost of nonquality.
We need to develop methods for measuring and
meeting customers expectations (needs and demands)
to provide both baseline and value-added services, successful in kind and in quality. It is said we are in the age
of knowledge. We pharmaceutics are well versed on the
medications-use process. Let this knowledge be useful for
our customers and society. Let us convey it in a clear,
effective way. It is just quality.

EF

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PROFESSIONAL DEVELOPMENT

Donald

E. Letendre

American Society of Health-System Pharmacists,

Bethesda, Maryland, U.S.A.

TYPES OF ~ E I ~ E N ~ ~ E S
A pharmacy residency is an organized, directed, postgraduate training program in a defined area of pharmacy
practice. Residencies exist primarily to train pharmacists
(called residents during the training program) by
providing them the opportunity to accelerate their growth
beyond entry-level professional competence in direct
patient care and in practice management, and to further
the development of leadership skills that can be applied
in any position and in any practice setting. Pharmacy
residents acquire substantial knowledge required for
skillful problem solving, refine their problem-solving
strategies, strengthen their professional values and attitudes, and advance the growth of their clinical judgment,
a process begun in the clerkships of the professional
school years but requiring further extensive practice,
self-reflection, and shaping of decision-making skills
based on feedback on performance. The residency
provides a fertile environment for accelerating growth
beyond entry-level professional competence through
supervised practice under the guidance of model
practitioners. Residents are held responsible and accountable for pursuing optimal medication therapy outcomes
in patients.
The residency also provides a fertile environment for
accelerating the growth of residents leadership skills.
Each residency offers the opportunity to exercise leadership under the watchful eye of effective leaders.
Examples of leadership skills and traits that may be
enhanced during a residency include trustworthiness and
integrity. comfort with ambiguity, organizational commitment, cross-cultural sensitivity, internalization of the
role of service to patients and other customers, recognizing the need for change, change management, persuasive
communication, team-building, confidence in ones ability to lead. and realistic self-assessment. To ensure
continuous development of future leaders in pharmacy
practice, it is widely accepted that leadership skill development be an integral part of pharmacy practice residency training.
Encyclopedia of Clinical Pharmacy
DOI: 10.1081iE-ECP 120006359
Copyright 0 2003 by Marcel Dekker, Inc. All rights reserved.

There are two types of residency programs: pharmacy

practice and specialized. Pharmacy practice residencies,
often referred to as general residencies, are intended
to provide training and education in the fundamentals of
exemplary contemporary pharmacy practice. Areas in
which the resident typically receives training are acute
patient care, ambulatory patient care, drug information
and drug-use policy development, and practice management. Because pharmacy practice residencies are offered
in a variety of practice settings (e.g., hospitals, health
systems, home care programs, long-term care facilities,
managed care environments, community practice sites),
the relative time that the resident might spend in each
area of practice will likely vary depending on the nature
of the site and the types of patients being served, as
well as the particular practice interests of the resident.
Fundamentally, pharmacy practice residencies are intended to produce a well-grounded general clinical pharmacy practitioner.
Specialized residencies are offered in a wide variety of
specialty practice areas and are intended to build upon the
practice experience gained through completion of a
pharmacy practice residency. The following is a list of
specialized areas of practice in which American Society
of Hospital Pharmacists (ASHP)-accredited residency
programs are offered:

* Critical care
Drug information
* Emergency medicine
* Geriatric
0
Infectious diseases
0
Internal medicine
* Managed care
0
Nuclear
0
Nutritional
Oncology
0
Pediatric
0
Pharmacotherapy

.,

837

838
0

Residencies

Pharmacy practice management

Primary care
Psychiatric
Subspecialities (e.g., cardiology, pulmonary, renal)

ASHP, in cooperation with its professional association

partners, administers the only process that grants
accreditation status to practice sites conducting residencies. ASHPs authority to grant accreditation is recognized by the Health Care Financing Administration
(HCFA). The accreditation process requires that each site
demonstrate compliance with established standards of
practice and offer a residency that meets the requirements
for training.
The process of accreditation ensures that accredited programs are peer reviewed and that requirements
for providing a state-of-the-art practice environment
are fulfilled.

VOLUTI

One of the fundamental issues that led to the founding of

the ASHP in 1942 was the need to train practitioners for
hospital pharmacy. This segment of practice was largely
ignored by pharmaceutical education. The first proposed
standard for postgraduate pharmacy training was published for comment in ASHPs The Bulletin in 1948.]
Since then, the requirements for training, as reflected in
the accreditation standards that have evolved throughout
the years, have always attempted to challenge programs to
be at the vanguard of practice.
The initial pharmacy residencies-or
internships
as they were called-were established in the 1930s, first
at the University of Michigan Hospital in Ann Arbor
under the direction of Harvey A. K. Whitney and
Edward C. Watts. Other early programs were at the
University of California Hospital in San Francisco, Duke
University Hospital, and St. Lukes in Cleveland. By the
early 1950s, it was estimated that at least a dozen
hospitals offered hospital pharmacy internship training.[*]
In December 1962, preceptors of the programs in existence at the time and other hospital pharmacy leaders
convened a meeting that in retrospect helped set the
framework for the accreditation process that is in use
today. At that meeting, the term residency was first

adopted (replacing the term internship) and participants agreed on a set of standards that would be used to
conduct the first accreditation site surveys in the spring
of 1963.
Throughout the early years, postgraduate pharmacy
training, as reflected in the standards, focused primarily
on the manufacture and preparation of pharmaceutical
products and on systems that could be implemented to
help ensure the integrity of those products up to the point
of administration. Moreover, substantial effort was placed
on providing trainees with the skills needed to pursue
leadership roles in the hospital pharmacy community. The
standards used to guide postgraduate training in institutional settings during the early years were reflective of
practice at that time in that they focused heavily on the
product side of the profession with little mention of the
end user, the patient.

Clinical ~ h a ~ ~ a c y
In the late 1960s and early 1970s, a few residency
programs began to place greater emphasis on patient care.
Clearly, these programs provided a philosophical shift
away from product-focused training and toward a greater
emphasis on pharmacist participation in patients drug
therapy management. They also helped facilitate the
clinical pharmacy movement that was emerging by
providing training to many of the early would-be clinical
pharmacy pioneers. The rapidity with which change was
occurring is perhaps best reflected in the Clinical Services
segment of the Qualifications of the Pharmacy Service
section of the revised Accreditation Standard for Pharmacy Residency in a Hospital that was approved in
November 1974:[31
The functions which comprise clinical services are
difficult to identify, partly because there is no common
agreement among practitioners as to the definition of
a clinical service, partly because there are clinical
components associated with most, if not all, of the service
functions of the hospital pharmacy department, and partly
because, in current practice, no clear distinction has been
made between clinical teaching activities and clinical
service activities. What are frequently purported to be
service activities are, more often than not, teaching (or
learning) activities. For this reason, in evaluating clinical
service activities, only those services. . .which are continuously performed even in the absence of students and
trainees, are considered.
This document marked the first time that requirements for clinical pharmacy services in postgraduate
training programs were addressed. Nonetheless, over the

Residencies

next few years, it became increasingly more difficult to

evaluate the growing number of clinical residencies
that were emerging against the hospital pharmacy accreditation standard. In those programs, the scope of
clinical services provided to patients grew substantially
and the attendant requirements for residency training to
assist in the delivery of those services were not addressed adequately in the accreditation standard-it
was like trying to fit the proverbial square peg in a
round hole. Hence, in 1980, ASHP approved the first
Accreditation Standard for Residency Training in Clinical
Maintaining accreditation standards for both hospital
and clinical residencies throughout the 1980s was
beneficial for a variety of reasons. Among them were
the following:

1. The professions diffeerentiated workforce needs.

Many staff pharmacist positions in organized
health care settings required a blend of the administrative and clinical skills that graduates of
general hospital residencies received, whereas
most management positions required graduates to
complete hospital residencies that focused primarily on honing a residents administrative skills
(most often these were tied to MS degree programs). However, graduates of clinical residencies
typically pursued faculty appointments and clinical practice positions that provided greater opportunities to deal directly with patients drug therapy issues.
2. A n insufficient level of residency candidates
holding advanced degrees. A prerequisite to
pursuing a clinical residency was the completion
of the PharmD degree or a commensurate level
of life experience to satisfy this requirement.
Although the number of pharmacy school graduates holding the PharmD degree continued to
increase throughout the 1980s, several clinical residencies struggled early on to obtain only candidates who had satisfied this prerequisite. This
situation was particularly noteworthy for programs
that were in regions where there was a paucity of
PharmD graduates.
3. Qualifications of the pharmacy service. Virtually
all departments of pharmacy that offered general
hospital residency training in the 1980s provided
some level of clinical pharmacy services. However, for the majority of these programs, the
level of clinical services provided-particularly
during the early 1980s-was inadequate to meet
the requirements of the clinical residency ac-

839

creditation standard. Hence, providing programs

with sufficient time to establish these services
under the direction of clinically competent practitioners was a key factor in maintaining both
the hospital and the clinical tracks in residency training.

The training of clinical specialists and pharmaceutical

scientists took hold in the 1970s and progressed
throughout the 1980s, paralleling advances in drugs
and drug delivery systems. Outgrowths of this movement
included the birth of the Board of Pharmaceutical
Specialties and the American College of Clinical
Pharmacy (ACCP). and the establishment of the ASHP
Special Interest Groups (SIGs). Throughout this period,
it became increasingly more accepted in the profession
that pursuing optimal drug therapy in patients, particularly when extremely complex drug regimens were
involved, often required a more sophisticated level of
service than was typically provided by a general pharmacy practitioner. Spurred on by the increasing need
for more highly trained individuals, in 1980, ASHP
approved the first Accreditation Standard for Specialized
Pharmacy Residency Trainingrs1 (frequently referred to
as the specialized umbrella standard) and the Supplementary Standard and Learning Objectives for
Residency Training in Psychiatric Pharmacy Practice,[61
which had been developed by the SIG on psychopharmacy practice. Since then, supplemental standards have
been approved for 16 specialized areas of pharmacy
practice. Two of these standards, pharmacotherapy and
infectious diseases, were developed jointly with the
ACCP and the Society of Infectious Disease Pharmacists, respectively.

eneies
ASHP approved the Long-Range Position Statement on
Pharmacy Manpower Needs and Residency Training17] at
the same time as the clinical residency standard. The
position statement intended to guide the thinking of
members about the categories of professional and technical pharmacy workforce needed in organized health
care settings and the types of training programs required
to meet that need. It also acknowledged that over time the
distinction between a generalist and a clinical practitioner would diminish and that, at some point in the
future, the need to maintain both clinical and hospital
residency standards would no longer exist.

840

Residencies

Consistent with this thinking, practitioners at the 1985

Hilton Head Conference on Directions for Clinical
Practice in Pharmacy] and the 1989 National Residency Preceptors Conference[] offered several recommendations to merge the hospital and clinical residency
standards. In particular, participants at these conferences
noted that, due to revisions in the hospital and clinical
residency standards, major segments of both documents,
especially those that relate to requirements in departmental services, were now virtually identical. Moreover,
it was also noted that portions of the requirements in the
general hospital standard-notably,
the training objectives for the clinical and drug information services
areas-approached
the clinical standard more closely
than in the past. Hence, in 1991, following more than 2
years of development that included a series of open
forums to receive input from residency preceptors on all
proposed segments of the document, the first Accreditation Standard for Residency in Pharmacy Practice
was approved.]
Adoption of the term pharmacy practice in the
new standard was significant. Clear consensus was established that the time had come to no longer distinguish
between clinical pharmacy practice and pharmacy
practice as the practice of pharmacy is inherently
clinical.[] As of July 1, 1992, all ASHP-accredited
general hospital and clinical residencies were converted
to residencies in pharmacy practice. Since then, three
separate standards governing pharmacy practice residencies have emerged: ASHP Accreditation Standard for
Residencies in Pharmacy Practice (approved April 25,
200 1); Accreditation Standard and Learning Objectives
for Residency Training in Pharmacy Practice (with
Emphasis in Community Care), prepared jointly by
ASHP and the American Pharmaceutical Association;
and Accreditation Standard and Learning Objectives for
Residency Training in Managed Care Pharmacy Practice,
prepared jointly by ASHP and the Academy of Managed
Care Pharmacy.

G
In all instances, the applicant to a residency must be a
highly motivated pharmacist who desires to obtain
advanced education and training, leading to an enhanced
level of professional practice. The applicant must be a
graduate of a college of pharmacy accredited by the
American Council on Pharmaceutical Education or be
otherwise eligible for licensure.
A residency in pharmacy practice is predicated on
prior clerkship and externship experiences. For this

reason, applicants to this type of program should have

completed a comprehensive clerkship and externship
program such as is required in contemporary clinically
based pharmacy curricula. For pharmacy practice residencies, there is no absolute requirement concerning the
type of pharmacy degree the applicant must possess.
However, it is clear that the PharmD degree provides the
applicant with the level of knowledge and skills needed
to meet the requirements for training in a pharmacy
practice residency and that, over time, this degree is
expected to become an absolute prerequisite for applicants. In all cases, it is the residency program directors
responsibility to assess each applicants baseline knowledge and skills, and to ascertain overall qualifications for
admission. The applicant should bear in mind that it is
permissible for programs to establish more stringent
entry-level requirements; hence, applicants must take
responsibility for contacting programs directly to determine specific entry requirements.
Prerequisites for entry into a specialized residency may
vary depending on the type of program. In all instances,
however, completion of the PharmD degree (or other
advanced degree in pharmacy) is required, except in
unusual cases (e.g., BS degree graduate who has been
in practice several years). Although completion of a
pharmacy practice residency is required typically for
admission to a specialized program, some programs may
accept an applicant without residency training provided
that the individual has a comparable level of professional practical experience. The reason for this requirement is that a specialized program requires the applicant
to have a sound foundation in general practice skills that
the pharmacy practice residency provides. Applicants
interested in pursuing specialized residency training are
urged to contact programs directly to determine the
specific requirements for application.

IN

There are a number of ways to learn about residencies.

However, the avenues that will likely provide potential
applicants with the most information are the ASHP
Residency Directory, the ACCP Directmy of Residencies
and Fellowships, and the ASHP Residency Showcase.
The ASHP Residency Director3 is a two-volume series:
Volume I covers pharmacy practice residencies and
volume I1 covers specialized residency programs. This
series is available through most colleges of pharmacys
departments of pharmacy practice and can be obtained
directly following application to the ASHP Resident
Match Program. The ACCP Directory of Residencies and.

Residencies

Fellowships is likewise available through most colleges of

pharmacy and can be obtained directly by contacting
ACCP. Both directories provide interested individuals
with a wealth of pertinent program information. Individuals interested in learning more about the residency
resources offered by these associations are encouraged
to visit the following web sites: www.ashp.org and
www.accp.com. Moreover, the following web sites offer
specific information about community-based and managed care residencies, respectively: www.aphanet.org
and www.amcp.org.
All students who are in their last year of pharmacy
school and are interested in residency training are encouraged to attend the ASHP midyear clinical meeting
in December of each year to participate in the Residency
showcase. The showcase is an area set up in booth
format that enables representatives of the various programs to meet personally with prospective residency candidates to address any questions they might have about
a program. Among other things, it provides applicants
with the best opportunity to meet preceptors and residents from each program, learn first hand about specific
elements of each program, and gain insights into programs that are often difficult to obtain through the directories. Because virtually all programs require candidates
to participate in on site interviews, participation in the
showcase can help a prospective candidate better identify those programs of greatest interest, which will help
minimize unnecessary travel expenses that might have
otherwise been incurred traveling to a less desirable
program. It is important to note that more than 98% of
all ASHP-accredited residencies typically participate in
the showcase.
Before searching for a residency, the pharmacist
graduate must determine his or her career objectives.
Because programs vary in terms of their relative degree of
emphasis in the areas in which training is provided, it is
particularly important for the applicant to determine, to
the extent possible, the area(s) that are most suited to
achieving career objectives. For example, an individual
interested in some dimension of ambulatory care would
be wise to pursue programs that offer a broad range of
experiences in this area of practice.
It is not uncommon for career objectives to change
following experience in the many areas of practice
typically provided in residencies. Hence, for applicants
who are unsure about future professional goals, the best
advise is to pursue training in a practice site that provides
a solid grounding in patient care because many of the
skills a resident will acquire are transferable across most
areas of pharmacy practice. To this end, it is essential that
potential applicants allow adequate time to review

841

program information, as well as ask program representatives about the overall strengths and weaknesses of their
program. Frequently, the best assessment of what a
program has to offer is through communication with
residents currently in the program.

Virtually all pharmacy practice residencies are required to

participate in the Resident Matching Program (RMP). The
only exception is those programs offered through the
military and public health services. Hence, it is essential
that potential applicants to these programs register for the
match. Applicants to specialized programs are not
required to participate in the RMP.
ASHP contracts with the National Matching Service
(NMS) to operate the RMP. The RMP ensures that each
pharmacy practice residency program is matched with
the preferred individuals who have applied and who have
selected the program as an acceptable site in which to
train. To apply for the match, applicants must contact
NMS directly (595 Bay Street, Suite 300, Toronto.
Ontario, Canada; telephone: 416-977-3431 or fax: 416977-5020). There is a modest application fee, and the
applicant agreement form must be received by January
15. Once NMS has received the agreement form. the
applicant will be sent a personalized match number (this
number will be required by all pharmacy practice
residencies to which the student graduate applies) and,
under separate cover, a copy of the ASHP Residency
Directory. As noted previously, the Directory pro\ ides
descriptions of all accredited programs, including important contact information. After consulting the Directory and identifying programs of interest. the student
graduate must request applications forms directly from
the individual residency program directors. not from
ASHP. Most programs require the applicant to participate
in an on-site interview; hence. student graduates are
advised to check directly with programs about application procedures as policies governing application do \ ary
among programs.

1. Fiske. R., et al. Standards for internships in hospital pharmacies. The Bulletin e ~ t e m ~ e ~ / O c ~ o
233-234.
2. Zellmer, W.A. Twenty-Five Years of Pharmacy Residency
Accreditation-Part
I. Early Efforts to Establish the
Program (Unpublished manuscript).

842

3. Accreditation standard for pharmacy residency in a hospital.

Am. J. Hosp. Pharm. February 1975, 32, 192-198.
4. ASHP accreditation standard for residency training in
clinical pharmacy. Am. J. Hosp. Pharm. September 1980,
37, 1223 1228.
5. ASHP accreditation standard for specialized pharmacy
residency training. Am. J. Hosp. Pharm. September 1980,
37, 1229-1232.
6. ASHP supplementary standard and learning objectives for
residency training in psychiatric pharmacy practice. Am. J.
Hosp. Pharm. September 1980, 37, 1232- 1234.
7 . ASHP long-range position statement on pharmacy manpower needs and residency training. Am. J. Hosp. Pharm.
September 1980, 37, 1220.
8. Directions for clinical practice in pharmacy. Proceedings

Residencies

of an invitational conference conducted by the ASHP

Research and Education Foundation and the American
Society of Hospital Pharmacists. Am. J. Hosp. Pharm.
June 1985, 42, 1287-1342.
9. Directions for postgraduate pharmacy residency training.
Proceedings of the 1989 National Residency Preceptors
Conference conducted by the American Society of Hospital
Pharmacists. Am. J. Hosp. Pharm. January 1990,47, 85126.
10. ASHP accreditation standard for residency in pharmacy
practice. Am. J. Hosp. Pharm. January 1992, 49, 146153.
11. Letendre, D.E. Reflections on the future of pharmacy
residency programs: An ASHP perspective. Am. J. Pharm.
Educ. Fall 1992, 56, 298-300.

PHARMACY PRACTICE ISSUES

Hospital General Val1 d'Hebron, Barcelona, Spain

INT
The development of a new drug, from its initial synthesis
until its approval and registration by the regulatory agency, goes through different stages in which clinical trials
are of paramount importance. The use of any drug in
humans requires the fulfillment of previous valid clinical
trials, which ensure the efficacy and safety of the drug and
guarantee that the basic ethical rights concerning the patients are respected."]
The pharmaceutical industry supports much of the drug
research in Spain, as it occurs in other countries."' The
main goal of most clinical trials initiated is to achieve data
on the efficacy and safety of a research drug, to complete
the corresponding file, and to present it to the regulatory
agency for its approval. Clinical research represents a
major component of investment and development activity
and takes an appreciable 36% of the research and development budget. This amount is similar to those corresponding to the European Community (39%) and to the
world as a whole (36%).13] It is important to notice that
since the 1980s the activity in clinical research, and
consequently the number of clinical trials that have been
developed, has increased continuously. Concretely, the
number of clinical trials developed in Spain has increased
from 88 during the period 1987-1989 to 520 in 2000
(until November). 1,4,51
From the profile of clinical trials developed in Spain,
different descriptive studies allow us to obtain a precise
picture. Most of the protocols evaluated are phase I11 (i.e.,
designed to fulfill the registration schedule and get the
approval of the regulatory agency) (42% and 49%, depending on the descriptive study), multicenter (79% and
98%), controlled (76% and 82%), and double-blind (42%
and 52%).r6,71According to the therapeutic activity of the
investigational drug, the most frequent groups were antiinfective and antineoplastic drugs.
Currently, as pointed out by Lunik,['] clinical trials are
a matter of great importance in the world of health care.
There are many sophisticated compounds under devel-

Encyclopedia of Clinical Pharniacy

DOI: 10.1081E-ECP 120006378
Copyright Q 2003 by Marcel Dekker, Inc. All rights reserved

opment, with specific properties and unique storage, preparation and monitoring requirements. The need for
clinical sites that can undertake quality research and the
need for health professionals who are able to manage the
more complex protocols is outstanding. Moreover, clinical trials have been put on aggressive time-to-development schedules. In addition, the research process has
become globalized, and efforts have been made to standardize good clinical practices (GCP) among the developed communities.
Within this context, clinical pharmacists face effective
participation in the research environment. Protocol development and execution, adherence to GCP and ethical
principles, together with the balance between revenues
and expenses, draw a specific working scenario that requires additional education and training, and represents an
emerging challenge for clinical pharmacists. Conceptually, pharmacists are responsible for the safe and effective
use of all medications, and this is especially important for
medications used in clinical trials.r91Different pharmacy
associations have been pointed out and have defined how
far drug development and its attendant activities are a
core function of the pharmacy
Although regulations and recommendations currently
in force in Spain assign the responsibility for studied
drugs to the investigator and the promoter- sponsor, rather
than the pharmacy service, it is clearly established that the
management of the samples for investigation must be
performed by the pharmacy. From this point of view, the
development of pharmacy-based investigational drug
services (the so-called Unidades de Ensayos Clinicos)
has been extensive, and more interestingly, the concept
that clinical trials represent a clear opportunity to expand
the role of the clinical pharmacist, has been widely
understood. Nevertheless, the attitude and participation of
pharmacists in clinical trials is not homogeneous within
the different hospitals. Passive reactions to innovate in
this field can still be detected, and the pharmacists'
training in many cases is not optimal, especially with a
lack of standardized guidelines for training residents.

843

Role of the Clinical Pharmacist in Clinical Trials (Spain)

844

The developmcnt and achievement of clinical trials is

based on ethical postulates, specific legislation in use, and
international guidelines for GCP research.
The assessment of health technologies is placed under
the Ley General de Sanidad.'"] This evaluation is guided
to determine the health, social, and economic impacts of
thc new technology under scrutiny, and is compared with
other alternative interventions. According to the Ley del
medicament^,"^' a clinical trial is defined as experimental evaluation of a substance or a drug, by means of
its administration or application to human, oriented to any
of the following targets:

the declaration of Helsinki and its succesive update^."'^

It will be necessary to obtain and document informed
consent, freely stated, from each subject of the study before the patient is included.
Furthermore, it is strongly recommended that investigators, sponsors, monitors, and all others involved in
clinical trials adhere to international standards for the
proper management of clinical trials (i.e., GCP released
by the International Conference on Harmonisation, involving the European Medicines Evaluation Agency
[EMEA], and the agency's counterparts in other countries
[United States and Japan]).""

To point out its pharmacodynamic or pharmacokinetic

effect.
* To establish its efficacy for a given therapeutic,
prophylactic, or diagnostic indication.
* To define it\ adverse effects profile and establish its
safety.
The term "experimental evaluation" refers to studies
that test substances nonauthorized as proprietary medicine
products or proprietary medicine products used in
nonauthorized conditions.
Clinical trials may only be carricd out when all the
following principles have been complied with:
0

The preclinic data about the product under study are

reasonably sufficient to guarantee that risks to the
subjects on whom the trial is conducted are admissible.
The study is bascd on current available data, and the
research represents, or may represent, an improvement
of scientific knowledge about humans or an improvement of human health, and by its design should
minimize thc risk to the subjccts.
The interest of the search for information justifies the
risks to which the subjects taking part in the clinical
trial are exposed.

The clinical trial developmcnt of drugs is regulated by

Royal Decree 561/1993,"" whereas clinical trials referring to health devices are regulated by Royal Decree 414/
1996."6' Clinical trials must be authorized by the Spanish
Medicine Agency with previous assessment by the ethics
commitees. The ethics commitces of clinical research will
be accredited by the Regional Health Authority in each
autonomous community, which has to communicate with
the Ministry of Hcalth and Consumer Affairs.'I4' Clinical
trials will be performed respectfully in relation to fundamental human rights and ethical postulates affecting
biomedical research in humans, following the contents of

The role of the clinical pharmacist in clinical trials is

going through a remarkable expansion process. Currently, there are different ways to integrate pharmacists
into the clinical research cnvironment.'4"C),20' Among
these, it is important to mention the contribution of clinical pharmacists, as staff members, to the ethics commitee of clinical rcsearch, their participation in the development of protocols by managing the dispensing and
use of investigational drugs, and their direct role as investigators, reviewing protocols and performing educational activities.
According to Royal Decree 561/93 (article 41),'Is1 on
the minimum requirements for the accreditation of an
ethics commitcc of clinical research, it is stated that at
least one hospital pharmacist must belong necessarily to
the commitee. In this way, clinical pharmacists are capable of evaluating methodological and logistical aspects
of each protocol and are competent to consider the ethical
issues of clinical trials.
As mentioned previously, Royal Decree 561/93 (article
18),"51 on the distribution of investigational drug samples, it is statcd that pharmacy service is responsible for
written acknowledgment of rcceipt, custody, and dispensing of the drug being evaluated. Together with this recognition are the latest guidelines for GCP."" The result
is easy to see. Ycars ago the problem for the pharmacy
was to take carc of the investigational drug, whereas
today the problem is to find resources to facilitate the
work load, which includes control of the entire process, as
stated by Ferrer.'221
Although regulations do not initially consider the role
of the clinical pharmacist as an investigator,"' it has been
stated that hospital pharmacists who are experienced in
research are fully prepared to participate in all processes
within the research environment.'23' In our understanding,
sponsors are still reticent to ask the pharmacist to play the

Role of the Clinical Pharmacist in Clinical Trials (Spain)

role of investigator in clinical trials. Nevertheless, because of the pharmacist knowledge of the principles
governing therapeutics, together with the intense relationship that they maintain with all the departments within
the hospitals, the hospital pharmacist is a valuable asset
for the design, development, review, and collaboration for
preparation of the protocol, as stated before.[241
Different surveys on the status of the role of the
clinical pharmacist in clinical trials have been pre~ e n t e d . [ ~ . ~The
' , ~ ~average
]
number of clinical trials
started per year and hospital is 9.6, and there is a wide
range of variation (up to 70 trials per year in large
hospitals). However, the latest data indicate a dramatic
increase in activity (around 100-150 trials per year). To
summarize the results, it can be stated that, in 76.2% of
hospitals, the pharmacy is the receiving site for investigational drugs, and 90.4% give written acknowledgment of
receipt. Direct dispensing to the patient is executed in
59.5% of centers, whereas dispensing to the investigator
was executed in 29.2% of hospitals.[31 Inventory control
of samples for investigation is intensively observed in
85.7% of institutions. If the point of view of the industry
is taken into account,[251similar results are obtained; that
is, distribution of the investigational drug is performed
by the pharmacy service in 82.8% of centers. In addition,
the pharmacy's role of dispensing drugs facilitates the
monitor's task in 71 % of cases. Interestingly, sponsors
recognize that pharmacists are investigators in 12% of
clinical trials, and that almost all of them (94% of sponsors) consider that the presence of pharmacist on the
ethics commitee of clinical research is essential for evaluating protocols. The value of the pharmacists' activity
in clinical trials is essentially not different from those
obtained in surveys developed in other countries.[261
Regarding human resources in this field, most centers
manage clinical trials by assigning one or more part-time
pharmacists or technicians who also work on traditional
activities such as drug delivery and drug information.
Therefore, it is difficult to estimate the number of protocols that can be managed by one full-time employee.
Only centers developing more than 70 clinical trials per
year are able to have one full-time employee dedicated for
clinical research.[31 This fact is linked to another extremely important issue: The revenue for pharmacy costs
is associated with research. In the current context of hospital operating costs, the structural resources and time
spent by the hospital pharmacy service for clinical trialrelated activities are difficult to justify. As it has been
pointed
only by carefully quantifying the costs for
providing this service and demonstrating that the benefits
outweight the costs, can the pharmacy justify a new
expansion program. In this way, a model for estimating
and evaluating the cost of pharmacy activity for any given

845

clinical trial was described. The average time spent per

trial was 91 hours, the average cost per trial was $1766,
and the average cost per patient was $174.[271Although it
is clear that clinical research activities should be funded
by specific economic resources, this consideration is not
always taken into account. Likewise, costs other than
those of the investigator, such as the costs of pharmacist
activities, are usually not taken into account when the
total cost of a clinical trial is calculated. Even, if these
costs are considered, they are fixed by people who are not
familiar with the pharmacy. Consequently, the current
sources for funding used to support the pharmacists' participation in clinical trials are not homogeneous, ranging
from fees charged to investigators (usually reimbursed
through the funds the investigator receives from the
sponsor) to the covering of the costs assumed by the
institution as part of the cost of participating in a research
program. This picture does not differ essentially from that
described by Rockwell et al. in their survey.[261
The economic impact of drug studies on the pharmacy
budget should be considered. Spanish regulation^"^] give
responsability to the sponsor for providing evaluated
drugs free of charge. Along these lines, two reports measured the savings resulting from the development of clinical trials. In one case, 23 clinical trials saved almost
0,30 million , during the period 1994-1996.[2*1 In a
second study, of the 105 clinical trials conducted in our
hospital during January 2000, 36 were evaluated. and the
results indicated a total savings of 1,65 million ; from
the rest of the studies, 55 therapies were evaluated without an established treatment, 2 were sponsored by the own
hospital, and 9 added, not substituted, the investigational
drug to the conventional treatment.[291These savings are
consistent with those corresponding to two pharmacybased investigational drug services in the United States
for fiscal period 1996- 1997.[301
From the institutions point of view, the Spanish Society of Hospital Pharmacy [Sociedad Espafiola de Farmacia Hospitalaria (SEFH)] considers the clinical trials a
matter of interest. As proof of this fact, there was a
meeting organized in the early 1990s in which more than
50 experts described and analyzed the role of the hospital
pharmacists in the growing world of clinical trials.[311
Furthermore, the reference text Farmacia Hospitalaria
dedicates an entire chapter to the clinical trials issue.[321
Nevertheless, whereas different associations (e.g. American Society for Health-System Pharmacists, Joint Committee on Accreditation of Healthcare Organizations)"]
have edited guidelines oriented to establish and define the
rules of the clinical pharmacist in clinical trials, the SEFH
has still not taken the step. Regarding educational programs for residents, there are no standardized guidelines
for rotations in investigational drug services, and each

846

Role of the Clinical Pharmacist in Clinical Trials (Spain)

hospital acts according to its own criterion. Moreover, the

recent edition of the resident's manual[331does not consider specifically the issue of clinical trials.
As mentioned previously, the role of the clinical
pharmacist in clinical trials in Spain must be considered in
three main ways: the participation in the development of
protocols by managing the dispensing and drug accountability by means of the pharmacy-based investigational
drug services; the contribution of the clinical pharmacist,
according to its condition of permanent member, to the
ethics commitee of clinical research; and the direct role as
investigators, conducting clinical trials.

INV

reporting incidences considered serious for the clinical

trial follow-up.
The description of the basic activities (in chronological
order) are as follows:

* Reception and study of protocol

Opening protocol file
Checking preceptive documentation
Protocol study
Meetings with monitors and/or investigators
Evaluating pharmacy participation
Opening computerized record
Establishing dispensing procedures
Information activities

The application of the current regulation^"^^ and GCP

recommendations['s1 leads to the constitution of the
investigational drug services within the pharmacy department in medium-size and large hospitals, which are
involved in the developing process of a great number of
protocols. The need for a specialized area in which to
manage clinical trials is widely recognized among pharm a c i s t ~ . [ In
~ ~addition,
]
the investigational drug services
allow hospital pharmacists to specialize in the concrete
area of clinical research, which is continuously evolving.
Moreover, the workload that clinical trials represent can
be accurately measured in the context of pharmacy service, and strategies for figuring costs and reimbursements
can be adequately carried out. In some cases, a clinical
trials agency is created in an attempt to integrate all clinical procedures in the hospital setting.[351
In our hospital (a typical third-level hospital having
more than 1500 beds), more than 150 clinical trials are
under development. Years ago, the pharmaceutical support unit for clinical trials was created; at the present
time, it involves a clinical pharmacist and a technician,
both full-time employees dedicated to clinical trials-related activity.
The main goals of the pharmacy-based investigational
drug services are as follows:

* To offer sponsors, investigators, and patients a guaranteed quality in the clinical trial process, by executing a correct reception, storage, and dispensation of
the investigational drug.
* To collaborate with investigators and sponsors in the
design of clinical trials and their follow-up.
e
To collaborate with the ethics commitee of clinical
research by offering information periodically on the
number of patients included in each protocol and

Drug management
Drug reception
Dispensing procedure
Storage
Stock management
Returned drugs management
Returning unused drug to sponsor
Feeding computer records of activity

* Finishing the study

Final inventory
Balance of drug accountability (receptioning/
dispensing)
Closing computerized record
Meetings with monitors and/or investigators
Closing the protocol file
Institutional or sponsor audits

As a function of the clinical trial or the nature of

the investigational drug, there are some other specific activities:
* Keep the randomization codes and opening them, if
necessary
0
Assigning patients to treatment groups, according to
randomization tables
Packing or acconditioning samples for suitable use and
administration
* Preparing solutions or mixtures and diluting the drug
for parenteral use under aseptic conditions
* Preparing or acconditioning samples that require
specific handling conditions (cytotoxics, biologics,
gene therapy)

Role of the Clinical Pharmacist in Clinical Trials (Spain)

847

Patient information and training (especially in the case

of outpatients)
Destruction of the returned or unused drug samples
through a suitable procedure
Evaluation of the patients and investigators adherence to protocol

two main programs: TRIALS[381designed by a working

party of the SEFH; and the recently updated GECOS,
designed in our pharmacy

For the adequate management of the investigational

samples in the context of the activity of the pharmacy, it is
necessary to consider the following:

The ethics commitee of clinical research is the institutional entity at the local institution that is responsible
for protecting the rights of human.[51 It plays a similar
role to the institutional review board in other
The main functions of this entity are to examinate the
methodological, ethical, and regulatory issues of each
protocol proposed for development in the hospital.
In detail, the commitee must evaluate, among other
things, the following:

Integrating the pharmacy-based investigational drug

activity within the pharmacy service, making use of
common settings and facilities
Establishing a differentiated flow to manage samples
for investigation within the pharmacy service
Storing the investigational drugs in a specific, unique
place, far from the conventional drugs
Establishing measures to keep the samples safe and
guaranteeing their integrity (i.e., locks in shelves,
temperature alarms)
Relaying on trained and specialized pharmacists and
technicians, even full-time employees, if the number
and complexity of clinical trials requires it
Defining an individual and concrete prescription sheet,
essential for dispensing the investigational drug
Keeping all documents and activity records in separate
files for each clinical trial
Computerizing all the clinical trial development, using
available software programs (purchased software or
developed in-house systems)
Establishing safety measures to guarantee the confidentiality of the protocol and the patients, to include
protecting investigational samples, files, and computer
programs
Elaborating suitable standard operating procedures for
all activities related to the clinical trial performance

It is important to define the reimbursment process for

providing the investigational drug services. There are two
main procedures: a fixed reimbursement per trial for
traditional services and a variable reimbursement estimated per clinical trial for other services;[361and a fee
structure (fixed and variable) in which each activity
involved in a clinical trial is
In our case, we
use the first procedure because of its simplicity. Nevertheless, a new fee questionnaire describing the cost of
each pharmacy-related activity is under evaluation.
As stated previously, a specifically defined computer
program is essential for maintaining inventory control and
accountability. There are different software programs
available, but beside conventional databases, there are

The appropriateness of the protocol related to the aim

of the study, its scientific efficiency, and the balance
between the expected risks and benefits of the new
therapy
The appropriateness of the investigator and the
research team responsible for developing the clinical
trial within the hospital
The informed consent document to be given to the
patients, from the point of view of the respect for
human rights
The clinical trial follow-up, from the beginning of the
study to the receiving of the final report
The ethics commitee is composed of members with or
without a background in health care and research. At least
one clinical pharmacist must be a member of the ethics
commitee. According to a survey,[31 the pharmacist is
president of the commitee in 4.8% of cases, secretary in
36.5% of cases, adviser in 12.1% of cases, or voting
member in 46.6% of cases. Thus, it is understood that
clinical pharmacists have the knowledge and the responsability to evaluate and monitor a diversity of clinical, methodological, and ethical aspects relating to
clinical trials.
For this reason, it is remarkable that, in many cases,
clinical pharmacists lead the follow-up process for the
clinical trials. It was in a pharmacy-promoted audit that a
serious deviation in GCP recommendations was detected.
In this study, it was concluded that compliance was adequate in 50% of protocols, so-so in 25% of cases, and
poor in the remaining 25%. Surprisingly, in 13% of the
patients, the informed consent document was not signed;
in 15% of the cases, the patients clinical records did not
reflect that the patients were included in a clinical
In a different way, a long-term follow-up detected that

848

only 32% of clinical trials previously evaluated by the

local ethics commitee was finally published at the end of
the protocol. Moreover, the sponsor sent the final report
of the clinical trial to the ethics commitee in only 33 of
135 finished clinical trials.[431
The role of the clinical pharmacist in the surveillance
of ethics principles and the maintenance of the rights of
human can also be notorious, especially when referring to
written information and the patients informed
The most relevant study undertaken in Spain that evaluated the quality of the written information provided to
patients was carried out by pharmacists involved in quality assurance and/or ethics ~ommitees.~]
The main outcome of this study was to confirm that most of the written
information to patients (65.3% of clinical trials) required
high-level studies to be completely understood by the patients. As far as we know, a more ambitious, multicentric
study is currently under development on the true comprehension and awareness that patients have of the clinical
trials in which they are involved.
As a whole, the pharmacists presence in ethics commitees allows the pharmacy service to solve practical
problems related to the execution of the clinical trial, prior
to the approval of the protocol. Moreover, by evaluating
methodological aspects of protocols, the clinical pharmacist is asked to develop future protocols, linking with
pharmacists role as clinical researcher.

It is clearly understood that pharmacy services and clinical pharmacists should play an important role in clinical research.[461In this sense, a survey noticed that a
clinical pharmacist was the investigator in 12% of clinical trials.[31 Nevertheless. the percentage of protocols
in which a pharmacist is integrated into the research
team is higher.
In fact, it is not rare that pharmacists collaborate
in activities that are not considered to be routine drug
management. The pharmacists may be responsible for
randomization of the patients in treatment groups. If the
study is double-blind, pharmacists can calculate dosages, keeping the investigator unaware of treatment
assignments. Nevertheless, the main field in which a
clinical pharmacist can expand is with the institutionally
sponsored research of off-label treatments. Such research may involve an existing drug product, a new
formulation, a new method or route of administration,
or any combination of these that is not covered by the
Spanish Medicine Agency-approved labeling; as well as
clinical trials that involve activities familiar to pharma-

Role of the Clinical Pharmacist in Clinical Trials (Spain)

cists according to their background (i.e., pharmacokinetics, pharmacoeconomics).

In the near future, within the context of our changing
health care environment and research environment, there
is a need for multidisciplinary approaches. The clinical
pharmacist should demonstrate, according to their expertise in the principles governing therapeutics. that they are
able to participate fully in this expanding process within
the research environment. Thus, a hospital pharmacist
would be valuable in the design, development, review,
and preparation of the protocol and, finally, in evaluating
and reporting results.

1. Ministerio de Sanidad y Consumo. Ensayos Clinicos en

Espaiia (1982- 1988); Monografias TCcnicas: Madrid,
1990: Vol. 17.
2. Vlasses, P.H. Clinical research: Trends affecting the
pharmaceutical industry and the pharmacy profession.
Am. J. Health-Syst. Pharm. 1999. 56, 171-174.
3. Quevedo, A,; PCrez. L.; Fernindez, A. Participacion del
farmackutico de hospital en la investigation clinica. Farm.
HOSP.1999, 23, 24-41.
4. Idoate, A,; Girildez, J.; Idoipe, A. Trials: Aplicacidn
informiitica para la dispensacion y control de medicamentos en fase de investigacih clinica. Farm. Hosp. 1995, 19,
24-30.
5 . Data not published. Pesonal communication. Agencia
Espafiola del Medicamento. Ministerio de Sanidad y
Consumo.
6. Vizquez. J.R.; Moncin, C.; Huarte, R.; Idoipe, A.; Palomo,
P.: Marco, R. Ensayos clinicos: Participacion del servicio
de farmacia. Farm. Clin. 1995, 12, 178-188.
7. Escoms, M.C.; Novoa, C.; Jodar. R.J.; SuiiC, J.M. Perfil de
10s ensayos clinicos evaluados en un hospital general
durante quince afios: Utilidad de un programa informiitico.
Farm. Clin. 1997, 14, 341-347.
8. Lunik, M.C. Clinical research: Managing the issues. Am. J.
Health-Syst. Pharm. 1999, 56, 170-171.
9. Phillips, M.S. Clinical research: ASHP guidelines and
future directions for pharmacists. Am. J. Health-Syst.
Pharm. 1999, 56, 344-346.
10. Cipywnyk, D.M. A survey of pharmacy-coordinated
investigational drug services. Can. J. Hosp. Pharm. 1991,
44; 183-188.
11. Giraldez, J.; Idoate, A,; Jimenez-Torres, N.V.; Ribas, J.;
Rodriguez-Sasiain, J.M. Aspectos Pricticos de la Participaci6n del Servicio de Farmacia en 10s Ensayos Clinicos
del Hospital. In Sociedad Espafiola de Farmacia Hospitalaria. Jornadas de Actualizacidn Sobre Ensayos Clinicos: Madrid, 1990; 65-118.
12. American Society of Health-System Pharmacists. ASHP
guidelines on clinical drug research. Am. J. Health-Syst.
Pharm. 1998, 55: 369-376.

849

Role of the Clinical Pharmacist in Clinical Trials (Spain)

13. Ley 14/1986, de 25 de abril, general de sanidad. Ministerio

de Sanidad y Consumo. B.O.E. no. 78, de 27 de abril de
1986.
14. Ley 25/1990, de 20 de noviembre, del medicamento.
Ministerio de Sanidad y Consumo. B.O.E. no. 306, de 22
de diciembre de 1990.
15. Real Decreto 561/1993, de 16 de abril, por el que se
establecen 10s requisitos para la realizacidn de ensayos
clinicos con medicamentos. Ministerio de Sanidad y
Consumo. B.O.E. no. 114, de 13 de marzo de 1993.
16. Real Decreto 414/1996, de 1 de mayo, por el que se
regulan 10s productos sanitarios. Ministerio de Sanidad y
Consumo. B.O.E. no. 99, de 24 de abril de 1996.
17. Declaracidn de Helsinki: recomendaciones para orientar a
10s mCdicos en 10s trabajos de investigacidn biomCdica con
sujetos humanos. Adoptada por la 18" Asamblea MCdica
Mundial (Tokio, Japdn, octubre de 1975), por la 35"
Asamblea MCdica Mundial (Venecia, Italia, 1983) y por la
41" Asamblea MCdica Mundial, Somerset West, Repdblica
de Sudifrica, octubre 1996.
18. Organizacidn Mundial de la Salud (International Conference on Harmonization of technical requirements for
registration of pharmaceuticals for human use) Good
Clinical Practice: Consolidated Guideline. Documento
no. E6GCPD12WP6. ICH Secretary. Ginebra, may 1996.
19. Ordovas, J.P.; Jimenez-Torres, N.V. El Servicio de Farmacia en el Ambito de la Investigacidn Clinica de Medicamentos en el Hospital. In El Ensayo Clinic0 Como
Tarea Cooperativa; Barlett, A,, Serrano, M.A., Torrent, J.,
Eds.; Monografias Dr. Esteve, Fundacidn Dr. Esteve:
Barcelona, 1992; Vol. 13; 27-35.
20. Rodilla, F.; Magraner, J.; Fuentes, M.D.; Ferriols, F.
Ensayos clinicos y su repercusidn en un servicio de
farmacia hospitalaria. Farm. Hosp. 1994, 18, 249-254.
21. Sacristan, J.A.; Bolaiios, E. Papel de 10s servicios de
farmacia en la realizacidn de ensayos clinicos: Punto de
vista de la industria farmackutica. Farm. Hosp. 1995, 19,
364- 367.
22. Ferrer, M.I. El control de 10s medicamentos de ensayo
clinico: Perspectivas y necesidades actuales. El Farmackutico Hospitales 1994, 52, 38-39.
23. York, J.M.; Alexander, J.G.; Barone, J.A. The value of the
clinical pharmacist in the drug development process. Clin.
Res. Pract. Drug Regul. Aff. 1998, 6, 23-39.
24. Gouveia, W.A. Regulatory Authority affecting american
drug trials: Role of the hospital pharmacist. Drug Inf. J.
1993, 27, 129-134.
25. Gallastegui, C.; Ascunce, P.; Divila, C.; Boado, A.
Servicios de farmacia y ensayos clinicos: Encuesta a la
industria farmackutica. Farm. Hosp. 1999, 23, 231 -237.
26. Rockwell, K.; Bockheim-McGee, C.; Jones, E.; Kwon,
I.W.G. Clinical research: National survey of U.S. phxmacy-based investigational drug services-1997. Am. J.
Health-Syst. Pharm. 1999. 56, 337-344.
27. Idoate, A,; Ortega, A.; Carrera, F.J.; Aldaz, A.; GirBldez, J.
Cost-evaluation model for clinical trials in a hospital
pharmacy service. Pharm. World Sci. 1995, 17. 172-176.
28. Barroso, E.; Ferrer, M.I.; Jbdar, R. Direct Economical

29.

30.

31.

32.

33.

34.

35.

36.
37.

38.

39.

40.

41.
42.
43.

44.

45.

46.

Impact of Clinical Trials 1994-1996. In 3rd Congress of

the European Association Hospital Pharmacists; Edimburgh: UK, 1998.
ValdCs, 6.; SuiiC, M.P.; Montoro, J.B. Impact0 econdmico
de 10s ensayos clinicos en un hospital general: Ahorro en
costes farmacCuticos. Farm. Hosp. 2000, 24, 93-94, (Esp.
Congr.).
McDonagh, M.S.; Miller, S.A.; Naden, E. Costs and
savings of investigational drug services. Am. J. HealthSyst. Pharm. 2000, 57, 40-43.
Sociedad Espanlola de Farmacia Hospitalaria. Jomadas
de Actualizacio'n Sobre Ensayos Clinicos: Madrid, 1990;
300 pp.
Idoate, A.J.; Cainzos, M.D.; Idoipe, A. Ensayos Clinicos.
In Farmacia Hospitalaria; Bonal, J., Dominguez-Gil, A.,
Eds.; Editorial MCdica Intemacional SA: Madrid, 1993;
645 -691.
Bermejo, T.; Cuiia, B.; Napal, V.; Valverde, E. Manual del
Residente de Farmacia Hospitalaria; Sociedad Espaiiola
de Farmacia Hospitalaria, 1999; 917 pp.
Jddar, R. Los ensayos clinicos constituyen una seccidn con
personalidad propia en el Servicio de Farmacia (entrevista). El FarmacCutico Hospitales 1994, 52, 6-8.
Gdmez, B.; Codina, C.; Ribas, J. In Clinical Trials Agency,
ASHP Annual Meeting, Orlando, Florida, 1999, poster
presentation, Intl-5 1.
Swartz, A.J. Reimbursement for involvement in investigational drug protocols. Am. J. Hosp. Pharm. 1989, 46, 1334.
Anandan, J.V.; Isopi, M.J.; Warren, A.J. Fee structure for
investigational drug studies. Am. J. Hosp. Pharm. 1993,
50, 2339-2343.
Idoate, A,; Ciraldez, J.; Idoipe, A,; Garrido-Lestache, S.
TrialsE:Aplicacidn informfitica para dispensacidn y control de medicamentos en investigacidn clinica. Farm. Hosp.
1995, 19, 24-30.
Gecos v1.1. Programa Multiusuario de Gestio'n de
Ensayos Clinicos Desarrollado para Servicios de Farmacia Hospitalaria; Grifols SA: Barcelona, Spain, 2000.
Oliveras, J.; Jddar, R.J.; SuiiC, J.M. Programa informatico
aplicado a1 control de ensayos clinicos. Farm. Hosp. 1990,
14, 83-87.
Wermelling, D.P. Clinical research: Regulatory issues.
Am. J. Health-Syst. Pharm. 1999, 56, 252-256.
De la Llama, F.; Gutierrez, P. Auditoria sobre ensayos
clinicos. Farm. Hosp. 1996, 20, 114- 117.
Monzd, M.; Pla, R. Seguimiento de 10s ensayos clinicos
finalizados y sus posteriores publicaciones. Farm. Hosp.
2000, 24, 107-108, (Esp. Congr.).
Ordovis, J.P. Consentimiento informado del paciente en
10s ensayos clinicos (editorial). Farm. Hosp. 1999, 23,
267-270.
Ordovis, J.P.; Ldpez, E.; Urbieta, E.; Torregrosa, R.;
JimCnez-Torres, N.V. Anilisis de las hojas de informacidn
a1 paciente para la obtencidn de su consentimiento
informado en ensayos clinicos. Med. Clin. (Barc.) 1999,
112, 90-94.
Ordovis, J.P. Investigacidn clinica en Espafia y servicios
de farmacia hospitalaria. Farm. Hosp. 1996, 20, 189-191.

PROFESSl 0NAL ORGAN IZATIONS

F

Society o f Hospital Pharmacists o f Australia,

South Melbourne, Australia

Federal councilors

The Society of Hospital Pharmacists of Australia (SHPA)

is the professional body that represents pharmacists
practicing in hospitals and similar institutions throughout Australia.
Established in 1941, the Society has a long-standing
commitment to the profession of hospital pharmacy and to
its role in ensuring optimal health outcomes for Australians. Fundamental to its success is the Societys culture of cooperation and contribution, which is reflected
in the high level of membership involvement.
In November 1999, SHPA members voted in a new
Constitution based upon revised Memorandum and
Articles of Association, developed to incorporate changes
in Corporation Law and to ensure that SHPA keeps
abreast of professional, technology, and social changes.
New membership categories were introduced as a
consequence of the new Constitution. Membership has
now expanded to include pharmacy technicians, inactive
members. and overseas members.

Neil Keen
George Taylor
Christine Maclean
Andrew Matthews
Paul Muir

SHPA is governed by a Federal Council which is supported by a divisional structure. There also local Branch
Committees in each State and Councilors are elected by
these Committees to represent the States at the federal
level. All Councilors, Branch representatives, and Division/Committee members work in a voluntary capacity.

Executive
Helen Dowling, Federal President
Naomi Burgess, Federal Vice President
Helen Matthews, Federal Treasurer
Sue Kirsa

Encyclopedia of Clinical Pharmacy

DOI: 10.1081E-ECP 120006304
Copyright 0 2003 by Marcel Dekker, Inc. All rights reserved

Executive director
Yvonne Allinson
The Federal Secretariat plays a critical role in serving
the needs of members and in supporting the activities
of the Society. It js based in the Societys offices in
Melbourne, Victoria, Australia.
The Divisions and Committees, which report to the
Federal Council, develop and implement policy in the
areas central to SHPAs goals. They include the Publications Division; Research, Grants and Development
Committee; Division of Specialty Practice; Liaison and
Promotion Unit, and the Division of Education. Each
is responsible for advising the Federal Executive of
new developments and opportunities that will allow
SHPA to continue its mission of promoting and developing the practice of pharmacy in hospitals and other
healthcare settings.
There are 15 Committees of Speciality Practice, which
reflect a wide range of professional interests and are responsible for contributing to the professional development
of SHPA members as well as maintaining and enhancing
standards throughout hospital pharmacy practice.

BERSHI
SHPA currently represents over 1,500 pharmacists and
pharmacy technicians working in hospitals and related
institutions. This represents over 80% of Australian
hospital pharmacists.

851

Society of Hospital Pharmacists of Australia, The

852

[41

TIV

issi

ent

SHPA is committed to promoting the quality use of

medicines through the ongoing development, application,
and implementation of leading-edge pharmacy practice in
hospitals and other healthcare organizations.

oak
e

Australian Drug Information Procedure Manual.

151
Drug Usage Evaluation-Starter Kit.
Directory of Hospital Pharmacy and Pharmaceutical
[61
Organisations.

To increase the status, influence, and profile of the

profession of hospital pharmacy.
To provide appropriate services to SHPA members.
To expand the career opportunities for members of
SHPA.
To foster strong and positive corporate unity within
SHPA.
To generate resources to maintain and expand SHPA
activities and to facilitate research.
To establish and promulgate standards and guidelines
in all relevant areas of pharmacy practice.
To ensure the availability and accessibility of comprehensive, relevant education.
To develop an effective network between SHPA and
other relevant organizations.
To provide appropriate services to organizations and
individuals external to the membership.

FIT
Members have access to a range of services and programs
aimed at enhancing professional standards and contributing to the ongoing development of hospital pharmacy
practice. These include:

s
These newsletters keep members up-to-date with news
and views at a national and local state level.

SHPA co-ordinates a comprehensive range of education

services for its members and other pharmacists and
healthcare workers interested in pharmacy and medication
use. Continuing Professional Development is delivered
throughout Australia, with branches in each state facilitating regular meetings on topical issues. SHPA works in
conjunction with universities to deliver postgraduate diplomas designed to give hospital pharmacists the skills for
pharmacy leadership. Postgraduate studies are recognized
by SHPA through the Society's Fellowship program.

SHPA administers a grants program aimed at supporting

research and development in the practice of hospital
pharmacy. During 1999, 103 grants were awarded with
just under A$140,000 being distributed. SHPA also actively supports research and development by commissioning studies in areas of major importance to the profession
including the impact of clinical pharmacy s e r v i ~ e s ' ~and
'~]
casemixbased funding and management for hospital
pharmacy. [9,lo]

ustralian Journ~lof Hos

This renowned publication provides a forum for the
exchange of knowledge and ideas about new initiatives
and developments in hospital pharmacy. It publishes the
research of new and established authors.

A key role of SHPA is advocacy for the profession and its

expanding role in provision of quality healthcare services.
SHPA represents the members, at both state and national
levels, on many important issues in relation to public
health policy, funding, and education.

oaks
SHPA publishes an impressive range of publications
including:
SHPA Practice Standards and Definitions."'
Australian Injectable Drugs Handbook.'21
[31
Clinical Pharmacy-A Practical Approach.

AN

The recently completed Clinical Pharmacy Intervention

Study['] was commissioned by SHPA to quantify the benefits of clinical pharmacist's interventions. Eight teach-

853

Society of Hospital Pharmacists of Australia, The

ing hospitals were involved in the study, the first multisite cost-benefit analysis of clinical pharmacy interventions in Australia. The results showed that over A$4
million per annum were saved by the hospitals because of
the direct intervention of clinical pharmacists in drug
treatments. The study will form a key component of a
campaign to increase awareness of the important role
hospital pharmacists have in ensuring safe, high quality,
and cost-effective healthcare and of maintaining adequate
levels of clinical pharmacy services.
With the rapidly aging Australian population in mind,
SHPA signed an agreement with the internationally recognized commission for certification in Geriatric Pharmacy in 2000. The agreement sees the two organizations
teaming up to offer the first examination-based competency assessment for Australian pharmacists. SHPA has
negotiated with the Australian Government for CCGPcredentialed pharmacists to access funding for clinical
services provided to patients in both hospitals and community settings.
Provision of quality educational services in pharmacy
and related areas is one of the core businesses of SHPA
and an area of ongoing expansion and development. In
recent times, the focus of these services has broadened
from predominantly addressing the needs of hospital pharmacists, to incorporating nursing and community pharmacist education. With the inclusion of pharmacy technicians in our membership starting in 2000, educational
needs of this group will be more formally addressed.
SHPAs most recent strategic planning cycle began in
February 200 1.

Biennial Clinical Pharmacy Conference

October 2000: Gold Coast, Queensland
October 2002: Sydney, New South Wales

iennial Federal CQn~erence

November 2001: Hobart, Tasmania
November 2003: Canberra, Australian Capital Territory

tate Branch Conferences

These meetings are annual or biennial, usually held in
alternating years with Biennial Federal Conference.

Annual general meeting

November 2001: Hobart, Tasmania

1. Practice Standards and Definitions; Johnstone, J.M.,

Vienet, M.D., Eds.; The Society of Hospital Pharmacists
of Australia: Melbourne, Australia, 1996, ISBN 0 9588944
9 3.
2. Australian Injectable Drugs Handbook, 2nd Ed.; Morris,
N., Ed.; The Society of Hospital Pharmacists of
Australia: South Melbourne, Australia, 1999, ISBN 0
9586881 17.
3. Clinical Pharmacy-A Practical Approach; Hughes, J.,
Donnelly, R., James-Chatgilaou, Eds.; Macmillan Education Australia Pty Ltd.: South Yarra. Australia, 1998,
ISBN 0 7329 4719 7.
4. Australian Drug Information Procedure Manual; Foran, S.,
Ed.; The Society of Hospital Pharmacists of Australia:
South Melbourne, Australia, 1996.
5. Australian Drug Usage Evaluation Starter Kit; SHPA
Drug Usage Evaluation Committee of Specialty Practice,
Ed.; The Society of Hospital Pharmacists of Australia:
South Melbourne, Australia, 1998.
6. Directory of Hospital Pharmacy and Pharmaceutical
Organisations; Vernon, G., Thomson, W.A., Eds.; The
Society of Hospital Pharmacists of Australia: South
Melbourne, Australia, 2001.
7. Allen, K.M.; Dooley , M.J. ; Doecke, C.J.; Galbraith, K.J.;
Taylor, G.R.; Bright, J.; Carey, D.L. A prospective
multicentre study of pharmacist initiated changes to drug
therapy and patient management in acute care government
funded hospitals, in press.
8. Dooley, M.J.; McLennan, D.N.; Galbraith, K.J.; Burgess,
N.G. Multicentre pilot study of a standard approach to
document clinical pharmacy activity. Aust. J. Hosp. Pharm.
2000, 30 (4), 150-157.
9. Burgess, N. The National Pharmacy Casemix Bridging
Study-Report
to the Commonwealth Department of
Health and Family Services; The Society of Hospital
Pharmacists of Australia: Adelaide, Australia, 1998.
10. Howitt, K.; Burgess, N.; Brooks, C. The Refinement and
Application of PharmGroup Classifications as a Management Tool f o r Competitive Neutrality in the Health
Industry; Report to The Society of Hospital Pharmacists
of Australia: Melbourne, Australia, December 2000.

PROFESSIONAL ORGANIZATIONS

Urbanizacidn Monteclaro, Madrid, Spain

The Spanish Society of Hospital Pharmacy (SSHP) is the

only national association of its kind to group together
hospital pharmacists in Spain. The society is very well
established within the profession due to its long tradition
of protecting the interests of the sector. It has not always
been easy to maintain the importance and representative
of the society. However, due to the efforts of its presidents and the pharmacists themselves, it is now one of
the most relevant hospital pharmacy societies in Spain
and in Europe.

The growth of the society is directly related to the incorporation of newly trained specialists who tend to join
the society once they have completed their studies and
participate in the development of new work groups. This
coupled with the experience and scientific knowledge of
the older members makes the SSHP one of the most advanced hospital pharmacy societies in Europe. For more
information about this organization, please visit our web
site at www.sefh.es.
With targets very similar to its present-day objectives
and members drawn from pharmacists working for charity, healthcare, and social service institutions, the Asociacidn Nacional de FarmacCuticos de Hospitales Civiles (National Civil Hospital Pharmacy Association)
was founded in Madrid in 1955. The promotion of the
hospital pharmacist's scientific, technical, and teaching
activities and, in general, of all issues relating to health
system pharmacy, remains enshrined in the bylaws today. After changing its name to Asociacidn Espafiola de
FarmaCeuticas Hospitalarios (the Spanish Hospital Pharmacists Association). the original association finally
became the Sociedad Espafiola de Farmacia Hospitalaria
(the Spanish Society of Hospital Pharmacists) in 1988.
Two landmarks in particular are closely linked to the
development of hospital pharmacy in Spain. The first was
854

the official recognition of the speciality; the second, the

creation of the Comisi6n Nacional de la Especialidad Espaiiola de Farmacia Hospitalaria (National Commission
for the Spanish Hospital Pharmacy Speciality), on which
the SSHP is represented. These two developments led to
the first Specialists in Hospital Pharmacy qualifications
being awarded in 1986.
In 1988, the foundations were laid for the modernization of the structure of what was then the association, with
the creation of a Madrid-based General Technical Secretariat. The General Technical Secretariat rapidly became integrated into the new structure, which was definitively introduced in 1992, after the relevant changes to
the bylaws, and under which the society's activities were
separated into a number of well-defined areas. Projects
currently in progress could then be included in, for instance, the economic, educational, publishing, or institutional relations areas. Projects such as Pharmacovigilance, GRDs, DDDs, and Information on Medicines and
Drugs were among the priority concerns.
Below is a list of the commissions and task forces
set up over the years. These bodies generate specific
projects on issues and subjects on which to focus within
their areas:
(Therapeutic Evaluation Commission)
Comisi6n de BioCtica (Bioethics Commission)
Comisi6n de Nutrici6n Artificial (Artificial Nutrition
Commission)
Comisidn de Normas de Procedimientos (Procedure
Regulations Commission)
Grupo Espaiiol de Farmacia Pedihtrica (Spanish Paediatric Pharmacy Task Force)
ComitC de Acreditacidn (Accreditation Committee)
Grupo de Estudio de Utilizacidn de Medicamentos
(Drug Use Task Force)
Grupo de Trabajo sobre GRDs (GRD Task Force)
In line with the spirit of the
phasis was placed on the areas
lications. In fact, so much work
areas that, in 1995, they were

bylaws, particular emof education and pubwas done in these two

moved to a separate

Encyclopedia of Clinical Pharnzacy

DOI: 10.1081E-ECP 120006380
Copyright C 2003 by Marcel Dekker. Inc. All rights reserved.

855

Spanish Society of Hospital Pharmacy

new headquarters also in Madrid and more suited to

their requirements.
Created in 1997, the Fundaci6n Espafiola de Farmacia
Hospitalaria (Spanish Foundation for Hospital Pharmacy)
is also closely linked to the SSHP.
Over the years, the SSHP has given top priority to its
educational and publications areas. With regard to the
educational area, this special interest has resulted in a
substantial number of courses, grants, prizes, and aids to
research. Efforts have been made to diversify so that
courses oriented toward residents have coexisted alongside others directed toward the staff, in an attempt to
cover the needs and requirements of the whole group.
Substantial aids are also available to ensure research
projects lead to complete, fully defined developments in
highly contemporary areas and subjects, often achieved
by multidisciplinary and multicentric teams chosen with
a view to encouraging scientific and professional exchanges. Aid is also available to outstanding young trainees, giving them access to specific knowledge in other
countries in lines of work that may or may not be directly
linked with our areas, but that are certain to provide a
wealth of new knowledge that can then be passed on
to the group as a whole.
Among the more than 130 publications issued by the
SSHPs publications area are a series of regularly revised
and updated monographs, general compendia, and regular
journal publications. The most outstanding of these is
undoubtedly the SSHP journal Farmacia Hospitalaria
(Hospital Pharmacy), which, over 20 years or so, has
provided a platform for some of the major landmarks in
the groups story, collaborating closely in diffusion and
the training of Spanish and foreign professionals. The
SSHP Infomzation Bulletin is another regular publication
that has also accompanied us in our eforts.
Activities undertaken by the area of institutional relations intensified in 1988, after the societys 1987 entry as
full member in the European Association of Hospital
Pharmacists, to which it had previously belonged as an
associate member. This was then accompanied by a
series of agreements with our institutions, including the
1989 Pharmacovigilance Agreement, the approval given in 1993 of the SSHPs Narcotics Computer Control
Programme, and the more recent official blessing for the
calculation of specific pharmacy weights in GRD, and the
Spanish Medicines Agency itself, with which we have
collaborated in a wide-ranging series of task forces in our
acknowledged role as experts in medicine and drugs.
Fully aware of this role, the society promotes and develops a range of studies, reports, and projects over a
range of contemporary and future health issues via the
foundation of the same name.

Finally, a brief mention of our annual Congress (first

held in Madrid in 1955) is in order. The Congress has
accompanied and evolved together with the society itself.
This year we held the 45th Congress, the latest in a
virtually uninterrupted series that provides a meeting place
for Spanish hospital pharmacists and that has now become a highlight on the international health care circuit.
This year, the 47th meeting of Congress is to take place in
Barcelona from October 1 to October 4 2002.
Besides the Congress, approximately 20 zoned scientific meetings are held every year, although the venues
for the coming year have not yet been decided. These
events keep the society alive and have helped it to grow
from the 50 or so associates who attended the first General Meeting in 1955 to the current membership of 1850.

VERNlN
residents of Honor
Felipe Gracia; Juan Manuel Reol; Manuel Ruiz-Jarabo;
Joaquim Bonal de Falgas
President
Eduardo Echarri Arrieta
~i~e-~residen~
Ma. Cinta Gamundi Planas
Secretary
David Garcia Marco
Treasurer
Rafael Molero G6mez
Member Zone 1
Ma. Jose Martinez Vizquez
Member Zone
Felipe de la Llama Vizquez
Member Zone 3
Carmen Lacasa Diaz
Member Zone 4
Manuel A16s Almiiiana
M e ~ ~ Zone
e r 5
Luis de la Morena del Valle
M e ~ ~ Zone
e r
Esperanza Quintero Pichardo

Spanish Society of Hospital Pharmacy

856

ember Zone 7
Antonio L6pei: Pastor

Technical Documentation OJfieer: Henar Martinez

HernjndeL
GRD Project Officer: Marc Montero Pardillo

ember Zone 8
Miguel Angel Wood Wood
Member Residents
Cristina L. Crespo Martinez

Eduardo Echarri Arrieta

Ma. Cinla Camundi Planas
Rafael Molero Gdmcz
David Garcia Marco
Felipe de la Llama VBzquez
Luis de la Morena del Valle

Farmaciu Hospitalaria: Esteban Valvcrde Molina

SSHP Infiwmation Bulletin: David Garcia Marco

General Technical Secretary: Isabel Crespo Gonzglcz

ClerkA: Ma. Luisa Avila Fernlindez; Manuela Florencio
Scrrano

Due to its long existence and experience, the SSHP now

has a very well-developed structure and is considered as a
solid reference within the health field. The society has
eight commissions, work groups, and task forces, more
than 130 publications, a bimonthly scientific journal, an
information bullctin, and educational activities (prizes,
courses, grants). This and the high degree of membcrship
among the pharmacists professionals make this society
an important and representative organization within the
medical field.

Boletin Informativo Extraordinario. Memoria 1991 -1909;

Sociedad Espafiola de Farmacia Hospitalaria, 1999.
Historiu de la Sociedad EspaAolu de Farmacia Hospitalaria.
Tomo I; Sociedad Espafiola de Farinacia Hospitalaria,
1995.
Historiu cle la Sociedad E.ypaAola de Farmacin Hospitalaria.
Tomo II; Sociedad Espafiola de Farmacia Hospitalaria,
1995.
Sociedad Espafiola de Farmacia Hospitalaria. Anuario; Meciitex,
1997.

PHARMACY PRACTICE ISSUES

Therapeutic Guidelines Limited, North Melbourne, Australia

IN
Therapeutic Guidelines Limited (TGL) is an independent,
not-for-profit enterprise that focuses on the writing, publication, and sale of prescribing guidelines for health professionals. This article presents the major initiatives of
TGL, its goals and organizational structure, and publishing process.

TGL had its genesis in the late 1970s, when a group of

enthusiastic individuals joined forces to improve prescribing in an Australian public hospital.
At that time. Melbourne hospitals were experiencing
an upsurge in the isolation of antibiotic-resistant organisms. There was concern among health professionals
that this was the result of the inappropriate use of antibiotics. A multidisciplinary group from the major Melbourne hospitals responded to the problem by developing an agreed position on what constituted appropriate
and cost-effective therapy for a range of common conditions. In 1979, the first edition of Antibiotic Guidelines
was launched.
In 1985, the Therapeutics Committee of the Victorian
Medical Postgraduate Foundation (VMPF-TC) was established to take responsibility for the distribution, promotion, and evaluation of the Antibiotic Guidelines, which
at that time was the only guideline booklet available.
In 1986, in recognition of the importance of appropriate drug use, a ministerial advisory committee. the Victorian Drug Usage Advisory Committee (VDUAC) was
established. The VDUAC believed the availability of independent information regarding drug therapy was integral to informed decision making by prescribers. In
light of the increasing acceptance and use of the Antibiotic Guidelines, the Committee resolved to build on
this concept and to produce additional prescribing guideline booklets.

Encyclopedia of Clinical Pharmacy

DOI: 10.1081E-ECP 120006375
Copyright G 2003 by Marcel Dekker, Inc. All rights reserved.

In conjunction with this expansion, a number of innovative educational marketing and outreach projects were
undertaken. The result was increased implementation of
the Guidelines in both hospital and community practice.
By 1996, the Guidelines were firmly entrenched and
growing rapidly. The VDUAC was responsible for the
production of the manuscripts, and the VMPF-TC for
publication, distribution, promotion, and evaluation of the
books. The number of titles was increased; the target
group was extended to include community practice; and
authorship was widened to ensure input from the most
eminent Australian experts.
With the expansion, however, administration became
difficult under the complex committee structure described above; therefore, in 1996 a separate entity, TGL,
was established under which all Guidelines activities
were consolidated.

TGL is a not-for-profit company limited by guarantee. It is independent of government and the pharmaceutical industry and is funded solely through sales of
its Guidelines.
It is governed by a board of nine directors, four of
whom are nominated by organizations that reflect the
genesis of the company: the Victorian Medical Postgraduate Foundation; the Victorian Drug Usage Advisory
Committee; The Royal Australian College of General
Practitioners; and the Commonwealth Department of
Health and Ageing.
The current directors of TGL are medically and pharmaceutically qualified professionals working in the areas
of health education, medicine, and pharmacy. They are:

* Professor D. Birkett (Clinical Pharmacology), South

Australia
* Dr. J.S. Dowden (Medical Publishing), Australian
Capital Territory

857

Therapeutic Guidelines Australia

858

Dr. J.E. Marley (General Practice), New South Wales

Dr. M.L. Mashford (Clinical Pharmacology), Victoria
0
Associate Professor F.W. May (Pharmacy), South
Australia
0
Dr. J.G. Primrose (International Medicinal Drug
Policy) Australian Capital Territory
* Professor J.W.G. Tiller (Postgraduate Medical Education), Victoria
0

The organization employs the equivalent of approximately ten full-time staff members, including the Chief
Executive Officer, Mrs. Mary Hemming, B Pharm., Grad
Dip Epi Biostat.
Staff are employed in the areas of production (both
print and electronic), information technology, marketing,
sales and administration, and evaluation. To supplement
the expertise and skills within the organization, consultants in finance, law, and marketing are utilized.
The Board appoints expert writing groups as ad hoc
committees, who work with editors to develop content
for the titles. Each writing group is chaired by a Director.

TGLs mission statement is promoting quality use of

medicines through the preparation, publication, and sale
of independent, authoritative, up-to-date, problem-orientated information.

The key objectives of TGL are:

To encourage the use of Therapeutic Guidelines by

health professionals to assist them in making therapeutic decisions to facilitate optimum healthcare.
To encourage the use of Therapeutic Guidelines internationally through licensing agreements with appropriate organizations.
To preserve the integrity of the organization through
strict policies for Directors, staff, and members of the
writing groups, on issues such as conflict of interest.
To maintain financial independence.
To establish strategic alliances with other organizations to further the objectives of the organization.
To increase the range of products, e.g., information for
consumers.
To allocate funds for research and development.

The core activity of TGL is the writing, publication, and

sale of Therapeutic Guidelines. These are published as a
series of pocket-sized books, and also in electronic formats suitable for both stand-alone and networked computers. All titles are regularly updated in iterative cycles,
thus allowing for shifts with evidence, response to feedback, and increased input over time.
The intention of the Guidelines is to provide prescribers with clear, practical, succinct, and up-to-date therapeutic information for a range of diseases. For experienced prescribers, the recommendations provide a
valuable second opinion against which they can compare their own prescribing. For those less experienced, the
recommendations form an acceptable basis for the management of patients. For other health professionals such as
pharmacists and nurses, Therapeutic Guidelines provide
information to support their contribution to the pharmaceutical care of their patients.

The Guidelines are derived from the best available scientific evidence, but the experience, insight and opinions of
Australian experts are an essential element of the writing
process, with the final text reflecting independent and
expert interpretation.
Because the Guidelines cover all common disorders
and not just those for which there is a body of evidence,
there are many instances where trial data are not available, where published data fail to answer questions relevant to prescribers, or where research findings may not
be relevant to local practice. To resolve gaps in the
evidence, recommendations for reasonable therapy are
developed, with criteria such as a drugs adverse effect
profile, long-term safety data, and cost being taken
into consideration.

eview and Endorsement

Critical steps in the development of the manuscripts are
an extensive external review process, reconciliation of
text with that of other relevant therapeutic guidelines, and
endorsement by national or peak bodies such as The
Royal Australian College of General Practitioners and the
National Prescribing Service.

859

arc
The evaluation unit liaises with a network of approximately 250 users (general practitioners, specialists, pharmacists, and students) to actively solicit feedback on the
various texts. Participants in the network are provided
with all titlcs free-of-charge, and staff visit these users
regularly to discuss and record comments.
Beforc any new edition is commenced, accrued fecdback on the previous edition is collated and passed on
to the writing group for consideration in the revision of
the text.

Internationally, TGL has been active. A model for an international publishing agreement has been established that
is working extremely well. A Japanese not-for-profit
organization (comprising doctors and pharmacists) is
licensed to translate and modify the texts to suit the Japanese market. The translated books are printed and sold
in Japan, with a royalty returning to TGL. Similar licenses
are in place with groups in China, Spain, and Russia.

ctr
The impact of written clinical guidelines is limited by
their accessibility at the time of decision making. Thercfore, the long-term goal of TGL is to optimize clinical
practice by integrating Therapeutic Guidelines into decision support systems, frcc of commercial bias, so they
can assist health practitioncrs at the time of consultation.
As an initial step toward this goal, all current titles
were converted into electronic versions suitable for both
stand-alone computers networks. The next step was the
aggregation and integration of all ten Therapeutic
Guidelines to produce a single comprehensive prescribing resource.
Alternate modes of delivery of the information are now
being investigated. For mobile prescribers in institutional
settings, the use of handheld computers is being explored.
For prescribers in office settings, information embedded
in prescribing software is being developed.

Research 1s an integral part of the organization and

the major focus of TGL research is on improving access to the Guidelines at the point of clinical decision
making and increasing integration of the Guidelines with
other information sources, prescribing modules, and patient databases.
TGL is an industry partner in a major research project,
which provides one postdoctoral and two doctoral
scholarships to further develop and optimize the production of electronic Therapeutic Guidelines, including the
integration of Therapeutic Guidelines with prescribing,
dispensing, and medical record management software.

The series includes ten titles in the Therapeutic Guidelines series and one Management Guidclines title:
Therapeutic Guideline\: Analgesic, Version 4
Therapeutic Guidelines: Antibiotic, Version 11
Therapeutic Guidelines: Cardiovascular, Version 3
Therapeutic Guidelines: Dermatology, Version 1
Therapeutic Guidelincs: Endocrinology, Version 2
Therapeutic Guide1ines: Gastrointestinal, Version 3
Thcrapcutic Guideline\: Neurology, Version 2
Therapeutic Guidelines: Palliative Care, Version I
Therapeutic Guideline\: Psychotropic, Version 4
Therapeutic Guideline$: Respiratory, Version 2
Management Guidelines: People with Developmental
and Intellectual Disabilities
The Guidelines are extensively used in public teaching hospitals, general practice, community pharmacies,
government instrumcntalitics, and medical and pharmacy schools.

Hemming, M. Therapeutic Guidelines: An AtlStrdlian Expcricnce. J. Pharm. Med. 2000, 14, 259-264.
http://www.tg.com.au.

PHARMACY PRACTICE ISSUES

St. Josephs Hospital of Atlanta, Atlanta,

Georgia, U.S.A.

I
In the 1980s, hospital pharmacies were important revenue
generators for the institution. However, the impact of
managed care coupled with reductions in public programs
has significantly changed how budgets of pharmacy departments are viewed. Today, pharmacy has moved from
being a revenue generator to a cost center for hospitals,
and pharmacy expenses have increasingly become the
focus of cost reduction strategies. In general, medication
costs represent only 4-8% of total hospital expenses.
However, this percentage is increasing due to the influx
of more costly medications, increased acuity of hospitalized patients, and the increasing number of medications
derived from technology.
Since the late 1990s, considerable literature has been
published on methods to manage drug expenditures in
the hospital setting. The method that is recognized as
being the most effective is a well-managed drug formulary system. Institutions with well-managed formulary systems demonstrate significant decreases in medication costs per patient day compared with institutions
without these systems.] The formulary system, as defined by the ASHP Statement on the Formulary System, is a method for evaluating and selecting suitable
drug products for the formulary of an organized health
care setting.12] Formulary management is a process employing various techniques to monitor the therapeutic,
economic, and clinical outcomes of medication use in
the organization.
Therapeutic interchange is the cornerstone of an effective formulary system. Therapeutic interchange is
defined as the exchange of one therapeutic equivalent
therapy for another with the intent of improving patient
outcomes.[21 Reductions in medication expenditures
resulting from therapeutic interchange programs are
realized by the reduction in the number of medications
routinely stocked and, in most instances, contractualbased reductions in drug costs. The primary intent of
this article is to provide an overview of the therapeutic
interchange process.

860

In this article, the following definitions are used:

Drug Formulaiy System: An ongoing process whereby

a health care organization, through its physicians,
pharmacists, and other health care professionals, establishes policies on the use of drug products and therapies, and identifies drug products and therapies that
are the most medically appropriate and cost effective to
best serve the health interests of a given population.[31
e
Drug Formulaiy: A continually updated list of medications and related information, representing the clinical judgment of physicians, pharmacists, and other
experts in the diagnosis andlor treatment of disease
and promotion of health.[31
Therapeutic Substitution: The act of dispensing a
therapeutic alternative for the drug product prescribed
without prior authorization of the physician. This is a
controversial procedure.[31
* Therapeutic Interchange: The authorized exchange of
therapeutic alternatives in accordance with previously
established and approved written guidelines or protocols within a formulary system.[31
* Generic Substitution: The substitution of drug products that contain the same active ingredients and are
chemically identical in strength, concentration, dosage
form, and route of administration to the drug product
prescribed.[31
Pharmacy and Therapeutics (P&T) Committee: An
advisory committee that is responsible for developing,
managing, updating, and administering the drug
formulary system.31 This committee should be composed of a variety of health care providers such as
physicians, pharmacists, nurses. microbiologists, administrators, discharge planning, quality assurance, and
risk managers.

In the United States, most health care systems establish

formularies based on the recommendations of the

Encyclopedia of Clinical Pharmacy

DOI: 10.1081E-ECP 120006336
Copyright 0 2003 by Marcel Dekker, Inc. All rights reserved.

Therapeutic Interchange

861

Pharmacy and Therapeutics (P&T) Committee. The first

guidelines describing a formulary system were published
jointly in the early 1930s by the Journal of the American
Medical Association and the Journal of the American
Pharmaceutical A~sociation.'~~
In 1965, the Joint Commission on Accreditation of Hospitals (JCAHQ) mandated that hospitals develop f~rmularies.'~]In 1959,
efforts by the American Society of Hospital Pharmacists
(ASHP) and the American Hospital Association (AHA)
were directed at providing a description of the role of the
P&T Committee. Based on the recommendations of the
two organizations, the P&T Committee was established as
the major committee within the health care organization
for determining which medications should be routinely
used in the hospital. Data from the American Medical
Association (AMA) suggest that 90% of hospitals have
some type of formulary.[61Historically, P&T Committees
have determined which medications were selected to the
formulary based on the safety, efficacy, and acquisition
cost of the medications.
The function of the P&T Committee has evolved
secondary to greater pressures caused by managed care,
costly medications, and expedited Food and Drug Administration (FDA) review processes. Modern P&T
Committees must consider the cost of therapy instead
of simplistically evaluating solely the acquisition cost of
the medication when deciding formulary status. Until
recently, cost effectiveness information was not a
routine component of data submitted to the FDA during
the drug approval process. In addition, shorter FDA
evaluations of new drugs mandate that hospitals, through
P&T Committees, constantly review information regarding clinical outcomes, medication errors, and adverse
drug effects long after the medication has been approved
for use.

RCHA

SS

The term therapeutic interchange is often used interchangeably with therapeutic substitution. There are
important differences between the two methods of
formulary management; therefore, the terms should not
be used in this manner. Based on the list of definitions
previously presented, the major difference between these
methods of formulary management is whether the prescribing physician has given approval of the interchange
of one medication for another or received notification
that the interchange occurred. In an effective therapeutic
interchange system, physicians are informed before the
alternative medication is dispensed and administered. A
great deal of controversy surrounds therapeutic inter-

change and substitution in the outpatient setting. The

Public Advocate for the City of New York contended
that the use of formularies and therapeutic interchange in
ambulatory care settings resulted in inappropriate, or less
appropriate, drug therapy.I7] Furthermore, this inappropriateness in drug therapy occurs in great part because
financial considerations-much more than clinical considerations-drive formulary decisions in managed care
organization^.^^] In a published comparison evaluating
the utilization of ambulatory services for patients in a
health maintenance organization (HMO), the use of formularies and therapeutic interchange was found to increase the utilization of health care resources.[81 Proponents of formularies and therapeutic interchange in the
outpatient settings argue that these criticisms are unfounded. The Academy of Managed Care Pharmacy
(AMCP) states that a well-developed and maintained
medication formulary decreases patients costs and improves patient care.[']
In the inpatient setting, therapeutic interchange has
been accepted by a number of medical and pharmacy
organizations. These organizations include the AMA
American Society of Health-Systems Pharmacists, and
the American College of Physicians.[21 These organizations support therapeutic interchange within the established guidelines of a formulary system to meet the
therapeutic and institutional goals for the ultimate benefit
of patient care.
In general, there are three mechanisms by which
therapeutic interchange can occur.[1o1 The first mechanism consists of a system whereby pharmacists independently substitute medications on the basis of their

Table 1 Therapeutic interchanges at SJHA

Low molecular weight heparins
Extended spectrum penicillins
First-generation cephalosporins
Second-generation cephalosporins
Third-generation cephalosporins
Proton pump inhibitors
H2 blockers
5HT3 inhibitors
Fluroquinolones
Oxazolidinones/streptagramins
Parenteral amino acids
Sedative hypnotics
Enteral feedings
Insulins
IV immunoglobulins
Narcotic analgesics
Multivitamins

862

own professional judgment, without the consent of the

prescribing physician. This mechanism is highly discouraged by the majority of professional organizations and is
considered illegal in several states. The second mechanism is the most commonly accepted. In this mechanism, medications are automatically interchanged with
prior physician approval based on established institutional protocols. These protocols are established through
the hospitals P&T Committee or through HMO policies. In most instances, this mechanism relies on the

Table 2 Guidelines for implementing a therapeutic

interchange program
Step I : Identify the feasibility of a therapeutic interchange
based on medication class usage trends, patient outcomes,
clinical trial data, medication error trenddpotential, adverse
reaction information, cost benefits, or resistance patterns.
Step 2: Determine the purpose of the therapeutic interchange.

If after determining that two agents are therapeutically

equivalent, cost savings can become an important factor of
the therapeutic interchange.
Step 3: Obtain support for the therapeutic interchange
from the P&T Committee, Antibiotic Subcommittee, and
any medical staff sections that would be involved in the

therapeutic interchange.
Step 4: Communicate the proposed therapeutic interchange to
members of the medical and hospital staffs. In general, input
should be obtained from members of the laboratory, nursing
staff, administration, risk management, key physician groups,
and quality improvement staffs.
Step 5: Once approved, advertise the therapeutic interchange

to the medical, nursing, administrative, and pharmacy staffs.

Communication can be in the form of medical staff
newsletters, pharmacy newsletters, mailings, inservices,
and posters.

Therapeutic Interchange

institutions computer system to activate the therapeutic

interchange. The last mechanism involves obtaining physician approval prior to each therapeutic interchange.
Although effective in some situations, this mechanism can
be time consuming for pharmacists, physicians, nurses,
and patients.
A survey published in 1992 by the American Society
of Health-Systems Pharmacists suggested that only 6 1%
of the hospitals participating in the survey had wellcontrolled formulary systems. ] Of these hospitals, 69%
had formulary systems based on the concepts of therapeutic interchange. Common medication classes involved
in therapeutic interchanges were antimicrobials, antacids,
and multivitamins. The medication class of antimicrobials is particularly suitable for therapeutic interchange.
Antimicrobials represent a pharmacologic class with multiple therapeutic redundacies. This pharmacologic class
represents approximately 10-40% of a typical hospitals
drug expenditures.[21
Saint Josephs Hospital of Atlanta (SJHA) is a 348bed, tertiary care, nonprofit hospital that specializes in
interventional cardiology, oncology, cardiac surgery, vascular surgery, orthopedics, and neurology. The hospital
currently has a drug budget of approximately $10 million.
Therapeutic interchange has been used extensively to
manage the pharmacy drug budget. It is estimated that
a well-managed formulary system based on therapeutic
interchange avoids $800,000 to $1 million annually based
on medication acquisition costs. Table 1 contains a listing
of therapeutic interchanges by medication class.
One of the most recent medication classes reviewed
for potential therapeutic interchange was the fluroquinolone antibiotics. A listing of the procedures involved
in the process is provided in Table 2. This listing should
serve as a guide for implementing a therapeutic interchange. Other guidelines have also been

Step 6 Implement the interchange. Physicians are generally

more accepting of therapeutic interchange programs if they

know that nonformulary medications can be obtained if
indicated. At SJHA, a nonformulary medication will not be
interchanged if brand necessary or do not substitute is
designated by the physician on the medication order.
R e p 7: Monitor the program for positive or negative impacts.

This is perhaps the most important aspect of developing a

therapeutic interchange program. Feedback regarding the
program should be continuously obtained from members of
the medical, nursing, discharge planning, and laboratory staffs
and, in some instances, from patients. Be prepared to modify
the program, if necessary.

CONCLUSION
When used appropriately, therapeutic interchange has
proven to be an extremely effective method of medication
cost management. An active and well-organized P&T
Committee is essential to the success of any therapeutic
interchange program. As the focus on the costs involved
with medication therapy in health care organizations
increases, P&T Committees will have to become even
more creative in methods used to promote, evaluate, and
monitor the effects of therapeutic interchange. The
evaluation of quality of life issues, pharmacoeconomics,

863

clinical outcomes, and humanistic/behavioral outcomes

will become increasingly important."'

7.

8.
1.

2.

Massoomi, F. Formulary managcment: Antibiotics and

therapeutic interchange. Pharm. Pract. Manage. Q 1996,
I6 ( 3 ) , 11 18.
American Socicty of Hospital Pharmacists. ASHP guidelines on formulary system management. Am. J. Hosp.

3.

d therapeutic interchange: The

health care setting makes a diffcrcncc. Am. J. Health-Syst.
Pharm. 1999, 56, 467 471.
4. Dillon, M.J. Drug F~ii-tnularl).Management in Managed
Care Pharmacy Practice: Navarro, R.P., Ed.; Aspen
Publishers, Inc.: Gaithersburg, Maryland, 1999; 145- 165.
5. Wade, W.E.; Spruill, W.J.; Taylor, A.T.; Longe, R.L.;
Hawkins. D.W. The expanding role of Pharmacy and
nd beyond. Pharma-

9.

10.

1 I.

~~

12.

13.
6.

American Medical Association. AMA policy on drug

formularies and therapeutic interchange in inpatient and

ambulatory care settings. Am. J . Hosp. Pharm. 11994, S / ,

180% 18 10.
Green, M.; Vasisht, R.; Martin, J. Compromiying Your
Drug Choice: How HMOs are Dictating Your Nexl Prescription; Public Advocate: New York, 1996.
Horn, S.D.; Sharkey, P.D.; Tracy, D.M.; Horn, C.E.;
James, B.; Coodwin, F. Intended and unintended consequences of HMO cost-containment strategies: Results
from managcd care outcomes project. Am. J. Manage. Care
1996; TI ( 3 ) , 253-264.
Managed Care Pharmacy ~act.c.heet-Therap~~uti~
Suhstitutian; Academy of Managed Care Pharmacy: Alcxandria,
Virginia, 1997.
Abood, R.K. Legal issues confronting the therapeutic
substitution of drug products. Clin. Trends Pharm. Practice
1995, 9, 1-11.
Crawford, S.Y.; Myers, C.E. ASHP national survey of
hospital-based pharmaceutical services 1992. Am. .I.Hosp.
Pharm. 1993, .50, 1371 1404.
Wall, D.S.; Abel, S. Therapeutic-interchange algorithm for
multiple drug classes. Am. J. Health-Syst. Pharm. 1996,
53, 1295- 1296.
Scsin, G.P. Therapeutic decision-making: A model for
formulary evaluation. Drug Tntcll. Clin. Pharm. 1986, 29,
581 583.

PHARMACY PRACTICE ISSUES

erican College of Clinical

Kansas City, Missouri, U.S.A.

Therapeutic interchange involves the dispensing of chemically different drugs that are considered to be therapeutically equivalent. Therapeutically equivalent drugs
are chemically dissimilar but produce essentially the
same therapeutic outcome and have similar toxicity profiles. Usually these drugs are within the same pharmacologic class. They frequently differ in chemistry,
mechanism of action, and pharmacokinetic properties, and
may possess different adverse reaction, toxicity, and drug
interaction profiles.
Interest in therapeutic interchange has risen as a result
of two primary influences: rapid expansion in numbers
of drugs within the same therapeutic class, and the need
to contain medication and health care costs while
maintaining rational drug therapy. Therapeutic interchange policies grant pharmacists the authority to interchange one drug for another without prior consent
from a physician, according to procedures outlined in a
specific policy.
The policies are usually developed and guided by an
advisory group such as the Pharmacy and Therapeutics
Committee. This committee is composed of physicians,
pharmacists, and other health professionals who combine
their expertise, knowledge, and experience to recommend
policies to the medical staff and administration of an
organization on matters related to the therapeutic use of
drugs. Among other duties, the committee 1) serves in an
advisory capacity to the medical staff and administration
in all matters pertaining to the use of drugs, including
therapeutic interchange; 2 ) establishes programs and
procedures that help ensure cost-effective drug therapy;
3) establishes or plans suitable educational programs
for the professional staff on matters related to drug use;
4) participates in quality assurance activities; and
5 ) initiates or directs drug use evaluation programs and
reviews their results.-71 Thus, a successful therapeutic interchange policy is directly related to the effective-

Copyright
864

1993 by the American College of Clinical Pharmacy.

ness of the Pharmacy and Therapeutics Committee in

performing its functions.
The concept of therapeutic interchange has aroused
much controversy and debate. Several definitions or interpretations exist, which have fueled this debate and
resulted in considerable confusion.
Concerns associated with responsibility, liability, communication, and monitoring influence an organizations
statement on therapeutic interchange. This publication
presents the American College of Clinical Pharmacys
(ACCPs) definition of and position on therapeutic interchange. It also reviews and discusses current views on
therapeutic interchange held by the American College of
Physicians (ACP), the American Medical Association
(AMA), the American Society of Hospital Pharmacists
(ASHP), the American Pharmaceutical Association
(APhA), the American Association of Colleges of Pharmacy (AACP), the Generic Pharmaceutical Industry Association (GPIA), and the Pharmaceutical Manufacturers
Association (PMA).

Organizations representing the medical, pharmacy, and

drug manufacturing communities have position statements or policies regarding therapeutic interchange.
These statements differ in their definitions and support
of the concept. For example, the ACP published a position paper in which therapeutic interchange in institutional and ambulatory settings is supported when a
functioning Pharmacy and Therapeutics Committee and
formulary system are in place.181In addition, the ACP
recommends that immediate prior consent be obtained
from the authorized prescriber with appropriate documentation of the substitution in a timely and proper manner. Although this document supports therapeutic interchange, the requirement of immediate prior consent
from the authorized prescriber may defeat the purpose. If
a pharmacist is required to call the physician to gain perEncyclopedia of Clinical Pharmacy
DOI: 10.1081E-ECP 120006409
Published 2003 by Marcel Defier, Inc. All rights reserved.

Therapeutic Interchange, Guidelines (ACCP)

mission to interchange medications, the physician can

either give or withhold permission, or provide a new
prescription order (verbal order). This new prescription
order can override the therapeutic interchange policy and
therefore negate its effectiveness.
Although it has not published a position statement or
paper on the topic, the AMA does not support the use of
therapeutic interchange in any setting. Their position is
evident when reviewing policies 23.023, 23.033, 23.035,
23.057, and 23.060 from their current Policy Compend i ~ m . [ These
~]
policies state firm opposition to the interchange of (1) . . . a drug product that is administered
in the same route and which contains the same pharmaceutical moiety and strength, but which differs in the
salt or dosage form; and (2) . . . a drug product containing a different pharmaceutical moiety but which is of
the same therapeutic and/or pharmacological class. At
their June 1990 annual meeting, the AMA House of
Delegates debated and adopted Resolution 161, which
states opposition to the establishment of a system at the
federal or state level for therapeutic interchange. The
resolution states that this will inevitably interfere with
the ability of the patients physician to assure that the
medication prescribed is dispensed to the patient, and
thus individuality of patient care can be lost.
Of note is the difference between therapeutic interchange policies endorsed by individual health care organizations, and regulations required by federal or state
laws. Federal or state regulations could be misinterpreted
as being blanket policies that grant pharmacists authority
to interchange medications across all classes and categories. Such regulations might also inappropriately suggest that pharmacists be given the authority to override
a physicians prescription without their knowledge.
Therapeutic interchange policies should not grant
prescribing authority to pharmacists. Patients can be
assured of getting the best care possible only when a
pharmacist acts in collaboration with a physician to
provide an optimal drug product.
Thus, both parties must endorse therapeutic interchange policies before such policies can be used effectively. Some states have enacted or proposed legislation
that requires physicians to be involved in the development
and management of therapeutic interchange guidelines,
whereas other states have proposed legislation that seeks
to prohibit pharmacists from enacting a unilateral interchange. The proposed or enacted legislation agrees with
ACCPs definition in that physician involvement is paramount to the successful development of guidelines
for therapeutic interchange, and pharmacists should not
make unilateral substitution of a drug.
The ASHP supports therapeutic interchange by
pharmacists when a pharmacist and a physician interrelate

865

on behalf of the patient.[lol They define therapeutic

interchange as the interchange of various therapeutically
equivalent drug products by pharmacists under arrangements between pharmacists and authorized prescribers
who have previously established and jointly agreed upon
conditions for interchanges. I1I They believe that an
advisory committee should develop these policies, that
the policies should be reviewed and revised over time,
and that prescribers should have the prerogative to override therapeutic interchange on behalf of patients. In
addition, ASHP recommends that pharmacists enacting
therapeutic interchange monitor affected patients to
identify and prevent any unexpected or untoward patient response.] Similarly, physicians should be
notified when a therapeutic interchange policy has been
enacted and be provided with educational materials supporting it when appropriate.
The APhA House of Delegates and the AACP support
the concept of therapeutic interchange of various drug
products by pharmacists under arrangements in which
pharmacists and authorized prescribers interrelate on
behalf of the care of patient^.""^"^] The AACP further
views initiatives to prohibit therapeutic interchange to
be counterproductive and confusing because this criticism
strikes at an important element of the clinical practice of
pharmacy. [13 They believe that pharmacy students are
adequately trained to participate in the clinical environment, and to assist in the development and process of
therapeutic interchange. To this end, AACP is committed
to training pharmacists who are competent to perform
these activities.
The GPIA supports the practice of therapeutic interchange in institutional or ambulatory settings where
a functioning P and T committee and a formulary system
are in place and where there is active consultation on
behalf of the patient between physicians and pharmac i s t ~ . The
~ ~ GPIA also supports an ongoing drug
utilization evaluation process for regular review of
therapeutic interchange policies and formularies, and for
providing information and education to prescribers. [14]
The PMA (representing pharmaceutical manufacturers
marketing brand name drugs) opposes therapeutic interchange. Its policy statement concerning drug selection
states that it supports those public policies which retain
the authority and responsibility for prescription drug selection exclusively with the individual attending physician, dentist or podiatrist.. .. Specifically, PMA believes
that inappropriate drug selection policies such as pharmaceutical or therapeutic substitution: (1) may adversely
affect a patients health, (2) raises serious legal questions,
(3) may result in increased cost for medical services
and (4) are highly inefficient and intrusive. [151 The
policy states, however, that it is not intended to address

Therapeutic Interchange, Guidelines (ACCP)

866

the manner in which hospital pharmacy practices are

implemented in an inpatient care situation. Direct physician involvement in determining the hospital formulary
distinguishes such formulary practices from therapeutic
and pharmaceutical substitution. Additionally, it is clear
that the inpatient care environment is a highly controlled
setting where patients are constantly being monitored
and, consequently, is much different than the outpatient
care situation.]
The view of many research-based pharmaceutical
manufacturers is based on the economic impact therapeutic interchange may have on their organizations.
Although this is an important consideration for their
welfare, we believe that the manufacturers should join
physicians and pharmacists in the quest to provide excellent medical care at reasonable costs, especially in
light of the federal, state. and local regulations directed
at achieving this goal. Such a commitment would foster
a better relationship among the represented communities.
The ACCP believes that if physicians and pharmacists communicate, collaborate, and jointly agree on
the purpose for and appropriate monitoring of therapeutic interchange policies, many of the opposing viewpoints outlined above can be brought together in an effort to provide state-of-the-art therapeutics and optimal
patient outcomes.

The ACCP supports therapeutic interchange policies

when pharmacists and physicians collaborate to develop
policies designed to provide patients with the best
possible care at the best overall price. These policies
should result from a synergistic combination of the
expertise and knowledge of pharmacists and physicians
whose common goal is to ensure optimum patient care.
They should not be interpreted as bestowing prescribing
authority on pharmacists. Although the policies may
vary in complexity, most involve the interchange of one
drug for another that is therapeutically equivalent. Thus,
they should not be viewed as or become blanket policies
allowing pharmacists to choose an alternative agent from
an entire class or category of drugs.
The ACCP supports the following guidelines for implementing therapeutic interchange policies within health
care organizations.

system and Pharmacy and Therapeutics Committee or

equivalent advisory committee.
Rationale
The success of any therapeutic interchange program is
related to the effectiveness of the Pharmacy and Therapeutics Committee or its equivalent body, and the drug
formulary system. This committee, representing both the
pharmacy and medical staffs, must develop, implement,
review. and change policies and procedures to ensure
optimum patient care while containing costs. Similarly, it
should recommend and assist in educating professional
staff regarding current therapeutic interchange policies,
the success of such policies, and any approved exceptions
to them.
The Pharmacy and Therapeutics Committee should
establish or assign a committee or department to monitor
the effectiveness of the interchange policies. Audits or
reviews should be conducted according to set policies.
Criteria should be developed and used to determine when
and why the therapeutic interchange policies may be
ineffective (see Guideline 11).The issues identified should
be addressed and the professional staff notified of
resulting changes to policies and procedures.
The specific types of institutional or ambulatory settings for which therapeutic interchange policies are most
likely to be effective are those that have drug formularies
with a functioning Pharmacy and Therapeutics Committee
or its equivalent. This may include, but is not limited to,
hospice settings, health maintenance organizations, community hospitals, university teaching hospitals, and ambulatory clinics affiliated with a hospital. If the policies
dictate that laboratory or medical record data should be
readily available to pharmacists prior to dispensing a
therapeutic alternative, the setting must provide access to
this information. Regardless of the setting, pharmacists
and physicians must have a good working relationship and
a mutual goal to provide excellent medical care while
containing costs appropriately.

Guideline II
A continuous drug use evaluation process must be in
place for regular review of endorsed therapeutic interchange policies and procedures.
Rationale

eline I
Therapeutic interchange is appropriate in institutional and
ambulatory settings that have a functioning formulary

Drug use evaluation (DUE) reviews the types of medications prescribed within an institution. This process
could identify prescription orders to which therapeutic

Therapeutic Interchange, Guidelines (ACCP)

interchange policies apply. Once these orders are identified, the success of the policies could be further
evaluated, reviewed, and reported. For example, one
would have to identify whether an approved alternative
agent was dispensed in place of the one originally prescribed. The DUE could also determine if appropriate
patient monitoring occurred following the interchange,
and whether the interchange resulted in an altered response. Results of these evaluations should be presented
to the Pharmacy and Therapeutics Committee or its equivalent to determine if changes or exceptions to existing
policies are indicated, or if additional educational endeavors should be made available to participating professional staff.

Guideline III
Therapeutic interchange, as defined herein, may be executed by pharmacists if the authorized prescriber is notified either verbally or in writing within a reasonable
time frame, and if the pharmacists have access to medical
records and appropriate laboratory or other test results as
required by the therapeutic interchange policy. Exceptions
to this procedure must be stated clearly in the policy.

Rationale
Therapeutic interchange policies and procedures should
describe in detail the conditions and processes for interchanging medications. These should include who has
authority to enact the interchange, special exceptions to a
policy or procedure, criteria to be evaluated before and
after the interchange occurs, and the definition of a
reasonable time frame for notifying the physician. For
example, the policy may not require that a physician be
notified for interchange of certain drugs, such as multivitamins. As another example, a reasonable time frame
for notification of the physician when therapeutic interchange has occurred may be defined as within 24-72
hours when the interchange involves antibiotics.

uideline IV
The Pharmacy and Therapeutics Committee or its equivalent should ensure that professional staff are educated
regarding the rationale, policies, and procedures for therapeutic interchange.

Rationale
Proper educational methods should be developed, implemented, reviewed, and revised as necessary to inform the

867

professional staff regarding the rationale, procedures, and

monitoring criteria for therapeutic interchange. These
methods may include, but should not be limited to,
newsletters, fliers, departmental meetings, meeting minutes, and publication of therapeutic interchange policies,
such as in an organizations formulary. Physicians should
be informed of the policies prospectively, and a list of
active policies should be readily available to the professional staff. Concerns or problems regarding the policies should be addressed to the Pharmacy and Therapeutics Committee.

eline V
The therapeutic interchange policies should define a
mechanism that enables authorized prescribers to disallow
therapeutic interchange.

Rationale
Therapeutic interchange may not be applicable to all
patients. For example, a patients preference may play a
role in a physicians decision to override a policy. An
acceptable method of overriding must be made available
to authorized prescribers. Ideally, it would allow one to
capture information regarding decisions to override policy
so that the data can be reviewed easily by an advisory
committee. This could, for example, be accomplished by
asking the physician to complete a brief survey or request
form for disallowing therapeutic interchange. The physician would have to notify the pharmacist either in
writing or verbally regarding the desire to override the
existing policy.

The guidelines were written by the following subcommittee of the 1990-1991 ACCP Clinical Practice Affairs
Committee: Terri Graves Davidson, Pharm.D.; Mary Beth
OConnell, Pharm.D.; Ryon Adams, Pharm.D.; Veronica
Moriarty, Pham.D.; Anthony Ranno, Pharm.D.; Nathan
Schultz, Pharm.D.; Barry Carter, PharmD., FCCP, Chair;
and Marsha Raebel, Pharm.D., FCCP. Other members of
the committee were Richard Berchou, Pharm.D., Dennis
Clifton, Pharm.D., Joseph F. Dasta, M.S., FCCP; Carl
Hemstrom, Pharm.D.; Donald Kendzierski, Pharm.D.;
Bruce Kreter, Pharm.D.; Louis Pagliaro, Pharm.D.;
Richard Ptachcinski, Pharm.D.; Christine Rudd,
Pharm.D., FCCP; and Dominic Solimando, Jr., Pharm.D.
Staff editor is Toni Sumpter, Pharm.D. Approved by the
Board of Regents on November 3, 1992.

Iherapeutic Interchange, Guidelines (ACCP)

868

From Pharmacotherupy 1993, 13(6):252-256, with

permission of the Amcrican Collcge of Clinical Pharmacy.

7.

8.

9.
I.

2.

3.

4.

5.

6.

American Society of Hospital Pharmacists. Statement on

thc pharmacy and thcrapcutics committee. Am. J. Hosp.
Pharm. 1984, 41, 1621.
Green, J.; Chawla, A.K.; Pong, P.A. Evaluating a restrictive formulary system by assessing nonformulary-drug
requests. Am. J. Hosp. Pharm. 1985, 42, 1537 1541.
Sesin, G.P. Thcrapcutic decision-making: A model for
formulary evaluation. Drug Intell. Clin. Pharm. 1986, 20,
581-583.
Butler, C.D.; Manchester, R. The P&T cominittec: dcscriptive survey of activities and time requirements. Hosp.
Formul. 1986, 21, 90 99.
Weintrauh, M. Effective functioning of the PXLT committee: Onc chairpcrsons view. Hosp. Formul. 1977, 12,
260 263.
Martin, LA.; Watkins, J.B.; Green, S.A., et al. Procedural
compliance and clinical outcome associated with therapeutic interchange of cxtcnded-spectrum penicillins. Am.
J. Hosp. Pharm. 1990,47, 1551-1554.

10.

11.

12.

13.

14.

IS.

Oh, T.; Franko, T.G. Implementing therapcutic interchange

of inlravcnous Fdmotidine for cimctidine and ranitidine.
Am. J. Hosp. Pharm. 1990, 47, 1547 1551.
American College of Physicians. Therapeutic substitution
and formulary systems. Ann. Intern. Med. 1990, 113 (2),
160- 163.
American Medical Association. AMA Policy Compendium. In Current Policies of the AMA House of Delegates
Through the I989 Interim Meeting; Chicago, 1990; 63-64,
67.
American Society of Hospital Pharmacists. Therupeutic
Interchange; Bethesda, Maryland, 1982.
American Society of Hospital Pharmacists. Guidelines on
formulary system managcmcnt. Am. J. Hosp. Pharm. 1992,
49, 648-651.
American Pharmaceutical Association. Position of the
American Pharmaceutical Association on the Issue oj
Th(,rupeutic.Interchange; Washington, DC, 1987.
American Association of Colleges of Pharmacy. Perspective on Therapeutic Interchange; Alcxandria, Virginia,
1987.
Generic Pharmaceutical Industry Association. Policy on
Therapeulic Interchange; New York, 1992.
Pharmaceutical Manufacturers Association. Policy Statement Concerning Drug Selection; Washington, DC, I 99 I;
1-6.

PROFESSIONAL DEVELOPMENT

Marwan S . Absuljoud
Henry Ford Hospital, Detroit, Michigan, U.S.A.

OPP
Transplantation of human tissues is one of the most
important medical achievements of the 20th century.
Transplantation began in 1902, with work of vascular
surgeon Alexis Carrel, who established many of the
vascular anastomosis techniques that led to effective
transplantation. A century later, transplantation has become a life-saving procedure for a variety of irreversible
acute and chronic diseases for which no other therapy is
available. Nearly every thoracic and abdominal organ
may now be successfully transplanted. In 1999, a total of
21,516 solid organ transplants were performed at centers
throughout the United States, of which 16,802 were
cadaveric and 4,714 were from a living donor."]
Increased experience and advances in surgical techniques, tissue preservation and posttransplant care have
helped to improve the overall success of transplantation.
In 1988, the 1-year graft survival of renal transplants
using cadaver grafts was 76%, but by 1999, the 1-year
cadaver graft survival rose to 89%. Results of living
donors also improved from 89% to 94% for the same
time period. Improvement in survival have also been
achieved for other solid organ transplants with approximately 70% to 80% of grafts functioning at 1-year
after transplantation. [
The success of any organ transplantation is due
largely to control of the immune system by immunosuppressive therapy to avert rejection of the allograft. Immunosuppressive treatment strives to prevent
allorecognition and subsequent destruction of the transplanted tissues. As a result, transplant recipients rely
on lifelong immunosuppressive drug therapy for preventing rejection and maintaining their graft. Pharmacists, as experts on immunosuppressive drugs have
a vital role in optimizing pharmacological therapy to
enhance transplant outcomes and minimize drug-related complications.

Encyclopedia of Clinical Pharniacy

DOI: 10.1081E-ECP 120006239
Copyright 0 2003 by Marcel Dekker, Inc. All rights reserved.

[TIES

Since the mid 1990s, the Food and Drug Administration

(FDA) has approved various potent immunosuppressive
drugs for use in transplantation. Currently, there are four
major classes of immunosuppressive drugs available:
corticosteroids, antilymphocyte, antimetabolites, and calcineurin inhibitors (Table l). These immunosuppressants are known to cause short-and long-term complications, including infections, cardiovascular disease,
and malignancy (Table 2).12-@ In addition, solid organ
transplant recipients may have their care further complicated by preoperative conditions. The majority of patients have chronic end-stage illnesses that are inevitably
fatal and necessitate their transplant. As a result, post
transplantation most patients are on complex prophylactic and therapeutic multidrug regimens, leading to
many drug-related complications that may compromise
transplant outcomes and significantly increase the cost
of transplantation.
From its inception, organ transplantation has been
approached in an extraordinarily multidisciplinary manner. The transplant team has historically included surgeons, immunologists, pathologists, internists, nurses,
dietitians, social workers, and spiritual representatives.
With continued success of transplantation and the immunsuppression-related complications, opportunities have
been created for many of the pharmacists that are now
members of various transplant teams throughout the United States. As part of the team, transplant pharmacists
provide direct patient care in a variety of settings, especially because they have the understanding of transplant
immunology and the immunosuppressants used to preserve the graft.
Appropriately trained transplant pharmacotherapy
specialists may practice in traditional clinical roles or
they may fill positions outside the usual sphere of
pharmacy practice. Many positions include a clinical

869

870

Transplantation Pharmacy Practice

Table 1 Immunosuppressive drugs

Antimetabolites
Calcineurin
inhibitors
Corticosteroids
Monoclonal
antibodies
Polyclonal
antibodies

Azathioprine, mycophenolate mofetil,

sirolimus
Cyclosporine, tacrolimus
Methylprednisolone, prednisolone
Muromonab-CD3, basiliximab,
daclizumab
Antilymphocyte gamma globulin-horse
Antilymphocyte gamma globulin-rabbit

practice site in addition to teaching and research opp~rtunities.[~

These individuals may provide inpatient or
ambulatory patient services. The ideal role would involve
both of these areas and, in so doing, ensure continuity of
care. Although the need to guarantee appropriate followup of treatment plans and monitoring is not unique to the
field of transplantation, the vast number of specialists and
subspecialists involved in the care of an organ transplant
recipient provides the pharmacist with many opportunities
to facilitate communications between members of the
transplant and nontransplant teams. Having pharmacists
coordinate the patients pharmacotherapeutic plan when
the patient is hospitalized and following discharge would
increase the consistency in treatment. This would have
the obvious benefit of improving patients quality of life
while reducing the cost of medical resources. The pharmacists focus adjusts as the patients clinical issues shift
from postoperative concerns immediately following the
transplant procedure to more chronic medical matters.
With the expansion of investigational immunosuppressants and clinical drug trials, many pharmaceutical drug
companies working in the area of transplantation have

Table 2 Possible complications of immunosuppressive drugs

Bone disease
Cardiovascular
Cosmetic
Gastrointestinal
Infections
Hematologic
Malignancies
Metabolic
Neurological
Ophthalmological
Psychological
Renal

Osteoporosis
Hyperlipidemia, hypertension
Acne, sun sensitivity,
hirsutism, weight gain
Peptic ulcer disease, diarrhea,
nausea, vomiting
Bacterial, fungal, viral
Leukopenia, thrombocytopenia
Solid tumors, post-transplant
lymphoproliferative disorders
Diabetes mellitus
Headache, tremor, neuralgia
Cataracts, glaucoma
Depression, mood changes
Acute or chronic dysfunction

created nontraditional roles for transplant pharmacists.

Pharmacists can use their skills as researchers (clinical or
basic science), educators, or medical information liaisons
to assist transplant centers to achieve their ultimate goal
of superior patient care.
The cost of transplant medications accounts for
approximately 25% of the total cost of care in the first
year after transplantation and up to 90% in subsequent
years.[* The absolute dollar amount of immunosuppressants and adjunct therapy is also very high. The average
wholesale price of one immunosuppressive agent may
range between $6,000 to $12,000 per patient per year. In
most situations, long-term immunosuppression consists of
double- or triple-combination therapy. Furthermore, in
the period immediately following transplantation, many
centers use induction therapy that involves expensive
agents such as monoclonal or polyclonal antibody prep a r a t i o n ~ . [ ~ With
~ ] the introduction of more induction therapies and other expensive immunosuppressive
agents, the potential for cost savings by increasing participation of clinical pharmacists is undoubtedly considerable and will continue to increase. Some literature
has demonstrated this in solid organ transplant patients,
but more rigorous studies will be needed before this
concept is widely accepted.

The clinical role of the transplant pharmacist is variable,

depending on the practice of the transplant center.
Although each clinician may be unique in his or her
position, all share the common goals and objectives of
improving patient care. Inpatient responsibilities may
include daily participation in medical and/or surgical
rounds. The transplant pharmacist offers recommendations to optimize drug regimens for patients, based on
their own history of illness. The use of immunosuppression therapy is often considered a balancing act between
Table 3 Drugs that interact with calcineurin inhibitors

Decrease concentrations of CNIs

Carbamazepine, cholestyramine, dexamethasone. isoniazid,
nafcillin, octreotide, phenobarbital, phenytoin. primidone,
rifampin, sulfadimidine, sulfinpyrazone, ticlopidine
Increase concentrations of CNIs
Clarithromycin, danazol, diltiazem, erythromycin, fluconazole,
fluvoxamine, grapefruit juice, itraconazole, ketoconazole,
methylprednisolone, methyltestosterone, nicardipine,
norethisterone, protease inhibitors, verapamil
CNIs, calcineurin inhibitors.

Transplantation Pharmacy Practice

871

suppression of rejection and immunosuppressive drug

toxicities. The fulcrum should always be adjusted to the
requirements of the individualized patient. For example,
with older transplant recipients in whom the immune
response is dampened, it may be more appropriate to
select a lower-intensity immunosuppressive regimen to
decrease side effects. In contrast, African Americans are
considered immunologic high-risk recipients with increased risk for rejection and, therefore, will require more
intense immunosuppression to ensure successful therapeutic outcome^.[^^.^^^ Certain patients may be predisposed to abnormalities that are part of their disease or a
result of the transplant. and a particular immunosuppressive drug may exacerbate or worsen them. To prevent
jeopardizing the allograft or further complications in these
patients, it may be necessary to modify the doses of certain immunosuppressants or avoid them entirely.
Once a particular regimen is chosen, pharmacists will
frequently perform pharmacokinetic and pharmacodynamic evaluations for immunosppressants, antibiotics,
and other agents. Many of the immunosuppressants such
as cyclosporine, tacrolimus. and sirolimus have significant intra- and interpatient differences that may lead to
suboptimal blood c~ncentrations.['""~~
Therapeutic drug
monitoring of immunosuppressive drugs is essential to
make accurate predictions for appropriate drug therapy.
Furthermore, many of the drugs used in the management
of transplant recipients are extensively metabolized by
the cytochrome P-450 enzyme system. Drugs, foods, or
nutrients that induce, inhibit, or compete for the same
isoenzyme could effect blood concentrations of these
immunosuppressive agents (Table 3)."6.171Drug interactions that increase blood concentrations could expose
transplant recipients to serious adverse effects, whereas
drug interactions that decrease blood concentrations may
cause rejection episodes and possible loss of the graft as
a result of inadequate immunosuppression. Pharmacists
can prospectively review the patient's medication profile
including over-the-counter (OTC) medications, herbs,
and dietary supplements to predict such interactions and
to help reduce adverse outcomes.

lacking, only that it has not reached the standardization

and review procedures achieved in other specialties.
Guidelines and consensus statements regarding the
optimal management of transplant recipients have not
been established because there are few circumstances in
which the support of one treatment over another is
overwhelming. This is probably due to the large sample
size required to show statistically significant differences
and the variability of patients in regard to demographics,
socioeconomics, and other risk factors. Most of the
resources currently available to aid in the selection of
specific medications are publications from the primary
literature. National and international conferences play a
significant role in disseminating information concerning
advances in therapy and new ideas. Symposia provide
another way to learn of contemporary practices, usually in
a setting that fosters networking while addressing individual practice issues. They also provide more opportunity to discuss cases with colleagues, draw upon the
experience of others, and learn innovative ways that other
centers address common problems. This puts a greater
onus on the transplant pharmacist to continuously review
the current literature, as well as to evaluate it based on its
merit and relevance to one's own practice setting and
specific population. Again, this provides an opportunity
for pharmacist involvement with the transplant team.
Evaluation of the literature from transplant and nontransplant sources becomes important. At times, one will
need to extrapolate information from nontransplant patients to overcome certain voids of information concerning transplant patients. Of course, experience and clinical
training will determine when this extrapolation is appropriate and when it is not. Herein lies part of the attraction of transplant pharmacy; one must possess very
specific knowledge on how to manage a unique group of
patients, namely organ transplant recipients, while being
able to deal with a multitude of medical issues, each of
which also requires specialist knowledge.
Table 4 Useful web resources
http://thedrugmonitor.com

TQCOL

It has been suggested that there are as many transplant

drug protocols for managing patients as there are
transplant centers. This situation has been created by the
fact that in the area of transplantation, there is an absence
of consensus statements and guidelines in the management of immunosuppressive therapy. This is not to imply
that adequate literature addressing transplant issues is

http://transweb.org
http://fujisawa.codmedinfo/cont_educ/tran-tmd/
http://transplantation.medscape.com/Home/Topics/
transplantatiodtransplantation.htm1
http://tpis.upmc.edu/tpis/immuno/compre.
htm

http://ntpr.registry@ mail.tju.edu
http://stadtlander.codtransplant/

http://mdconsult.com
http://clinicaltrials.gov

http://unos.org

872

Table 4 outlines various transplant web resources that a

pharmacist specializing in transplantation may find useful. Although some of these web sites include information
for patients, others are for health care providers working
with the transplant recipients.

EDUCATION
Transplant pharmacists are considered unbiased resources
for drug information that promotes better patient care.
This service may be provided to a variety of individuals
and disciplines, such as patients, caregivers, and health
care providers, as well as medical residents, new pharmacists, and pharmacy students.
During the first year after transplant surgery, the
average drug regimen of a transplant recipient consists of
at least 10 different medications with variable time
schedules for administration. For many patients, the
significant number of medications and their complex
schedules can be overwhelming. This creates the potential
for errors and drug noncompliance at a time when the
patients condition makes them especially vulnerable to
the results of subtherapeutic phannacologic treatment.
Pharmacists can educate patients on indications for
immunosuppressive therapy, appropriate use of drugs,
anticipated adverse effects and expected outcomes
(Table 5). Drug regimens must be simplified and made
relevant to a patients individual needs. As time passes
after transplantation, the risk of graft rejection will decrease. As a consequence, patients have frequent alterations in therapy as their risk for infections and other
complications decreases with the reduction of their immunosuppressive therapy. Patients must be kept aware
of these changes, and teaching opportunities during each
admission and clinic visit should not be missed. Because
of the potential for drug interactions with immunosuppressants, pharmacists usually counsel patients not to

Table 5 Common educational needs transplant pharmacists

address with patients
Signs and symptoms of infection
Medication adverse effects
Management of adverse events
Drug-drug and drug-food interactions
Blood glucose control and insulin requirements
Pain management
Over-the-counter medication use
Alternative medicine use
Nutritional requirements
Drug compliance

Transplantation Pharmacy Practice

treat themselves with any of the numerous OTC medications. The pharmacists may also develop a variety of
educational tools to enhance patient learning.] This
could take the form of recording audio instructions for
visually impaired diabetic patients, creating daily medication logs, and providing written information in language appropriate for patient understanding.
Patient noncompliance to immunosuppressive therapy
is a significant cause of graft f a i l ~ r e . [ ~ Some
- ~ ~ ] investigators have reported rates ranging from 2% to a high of
43% in pediatric renal transplant recipients.[231In addition
to the complexity of the drug regimen, other factors may
lead to drug noncompliance. These include concerns in
physical appearance due to the side effects of immunosuppressants, poor provider-patient communication (e.g.,
dosage change that is not fully explained), depression or
anxiety, dissatisfaction with medical care, cost of drugs,
and misconceptions that missing doses will not cause
r e j e ~ t i o n . [ ~Potential
~ , ~ ~ ] health and economic consequences of noncompliance to immunosuppressive therapy include cost of initial and additional prescriptions, physician
visits, clinic or emergency department visits, hospitalization, diagnostic costs and additional care such as dialysis
in case of renal transplant recipients.[261
Pharmacists can provide various strategies for maintaining drug compliance. They can help patients to select
a reminder or cue such as clock times, meal times, or
daily rituals or activities to assist with medication administration. Meeting with patients more frequently to
assess compliance also reinforces the drug regimen.
Intervention programs using support groups and partnerships between the recipient, family, and transplant team
have also been shown to be effective strategies to increase
compliance.[271Increased emphasis on patient counseling
and education about the drug regimen can lead to improved compliance.
A major role of all pharmacists in hospitals and
outpatient clinics encompasses education for medical and
nursing staff, as well as other colleagues. Understanding
the various immunologic pathways that can be modified
is essential to understanding the role of the various
immunosuppressive medications and their subsequent
effects. Knowledge regarding identification and treatment of complications, such as infections, hypertension,
diabetes, hyperlipidemia, osteoporosis, renal insufficiency, depression, and cancer, just to name a few, is
crucial when caring for transplant recipients. As these
patients live longer and become healthier, new issues
arise as they contemplate such possibilities as conceiving
children, concepts that would not have been entertained
previously. Although at one time management of transplant recipients may have revolved around surgical care

Transplantation Pharmacy Practice

and immunosuppression, it now includes every discipline from internal medicine to obstetrics and gynecology and all the pharmacologic issues that go along
with each specialty. Each of the professionals contributing to the care of the patient needs to have some understanding of the transplant pharmacotherapy treatment
used. This will undoubtedly affect their differential diagnosis, how they treat the patient, and what kind of
problems need to be brought to the attention of the transplant team, who often continues to care long-term for the
patient in some
Education may be provided through informal in-service programs about new drugs, new drug indications,
and countless other topics. Tailoring these educational
programs to each discipline may pose a challenge to the
presenter because of the varied background and needs
of the many people involved in the care of a transplant
patient. For example, educational needs of a surgeon
are often different from those of a medical specialist
such as a nephrologist or hepatologist or those of a
nurse or pharmacist.
Pharmacists may also perform formal presentations at
professional meetings and symposia. Drug information
can be regularly disseminated in a form of drug monographs, newsletters, and continuing education articles.
In addition, many transplant pharmacy specialists have
didactic teaching responsibilities, provide clinical rotations for pharmacy students in transplantation, and serve
as preceptors.

ESEARCH
The development of newer immunosuppressive drugs has
promoted a need for investigating their safety and efficacy
to ensure appropriate use. Research on various approved
or investigational immunosuppressants continues to be
executed at an accelerated rate. Many transplant pharmacists have established precedents for successful drug
research practice^."^'^^'^^^ Most work with clinically
relevant trials in areas such as drug pharmacokinetics,
pharmacodynamics, and patient outcomes. This provides
the transplant pharmacist with additional avenues to
demonstrate to the team his or her unique suitability at
coordinating and conducting such research. As is recognized by the FDA, the role of a person with a doctorate
degree in pharmacy can be to serve as primary investigator in collaboration with physicians. This is due to the
recognition that pharmacists have the appropriate training
and the clinical perspective to participate or manage
clinical drug research. Pharmacists may be involved in all
aspects of the research project, including protocol de-

873

velopment, approval from the institution's Investigational

Review Board, budget analysis, patient recruitment, obtaining informed consent, data gathering, data analysis,
drawing conclusions, and finally submission for presentations and publication.
Since the infancy of transplantation, the goal of drug
therapy has been to create an agent that can promote true
immunologic tolerance, defined as graft acceptance without immunosuppression. As a result, the National Institutes of Health, various pharmaceutical companies, and
many independent scientists have all taken this into
developments to foster investigation into strategies that
might help to discover such a compound. Some pharmacists are currently performing such translational research in the hope of eventually crossing paths with
clinical practice.
Emphasizing cost containment while achieving rational pharmacotherapy has become an important feature of
many formulary decisions. A transplant pharmacist may
also develop pharmacoeconomic studies that examine
the financial impact associated with different immunosuppressive regimens. Such analysis extends beyond
comparison of the acquisition costs of the individualized
immunosuppressive agent. Other charges, such as the
costs of organ procurement, room and board, laboratory
tests, operating room, nuclear medicine, and physician
and surgeon professional fees, must also be included
because they may substantially add to the total cost of
transplantation. Feasibly, a more expensive immunosuppressant agent or regimen may prove to be more cost
effective than cheaper agents if graft survival is increased
or the incidence of morbidity is de~reased.'~']
A panel of
investigators drawn from major transplant centers and
representatives of the pharmaceutical industry drafted
standards for economic and quality-of-life studies. This
panel recommended specific guidelines for the design and
conduct of trials for economic analysis of transplantation.
These recommendations serve as a template for better
design of pharmacoeconomic trials to evaluate the cost
effectiveness of transplantation in the future.
The field of transplantation, therefore, is fertile ground
for numerous pharmacist-driven research projects of
significant clinical and experimental relevance. The
results of such research can serve to guide protocol
decisions to improve patient outcomes and, ultimately,
improve patient's quality of life.

Although the available number of transplant-related

industry practice positions is relatively small, some

Transplantation Pharmacy Practice

874

pharmaceutical companies offer medical or scientific

liaison positions well suited to pharmacists with prior
transplant experience. These positions require the individual to interact with physicians, nurse coordinators,
and other pharmacists regarding issues of research and
education, Coordination of multicenter studies and facilitating communication among centers through symposia,
continuing education programs, and advisory boards are
especially vital in the transplant discipline. Many transplant practitioners rely heavily on these sources for upto-date clinical information. Advances in transplantation
pharmacotherapy are happening with increasing frequency each year to the point where there is no standard
of practice. Much reliance is placed on experts in the
field, often identified by industry professionals who travel between centers.

2.

3.

4.

5.

6.
7.

8.

Pharmacists working with transplant patients are continuing to define their practice model to meet the pharmaceutical and primary care needs of all transplant
patients throughout the spectrum of care. The role for
transplant pharmacists will continue to expand as the field
of organ transplantation becomes a viable option for more
patients. In a relatively short period of time, for example,
kidney transplantation has gone from being an experimental procedure in the 1950s to being a cost-effective
treatment for end-stage renal failure. The type of practice
one chooses does not need to be limited to any one of the
possibilities listed here. A transplant pharmacist position
can involve different combinations of these responsibilities and others, as necessary, tailored to the preferences
of the practitioner and the needs of the center. As
transplantation of other organs becomes more attractive,
the need for qualified pharmacists as part of the transplant
team will continue to increase. The field of transplantation provides numerous opportunities for pharmacists,
many of which can still be individualized to suit the
strengths and preferences of the practitioner. Of all the
reasons that demonstrate the need for transplant pharmacists, none is as convincing as the needs of the patient.
The patients needs define what roles are available to
pharmacists and how valuable those services are to the
transplant community and society in general.

9.

10.

11.

12.

13.

14.

15.

16.

1. 2000 Annual Report. In U.S. Scientific Registry of

Transplant Recipients and the Organ Procurement and

17.

Transplantation Network: Transplant Data; U S . Department of Health and Human Resources and Services
Administration: Richmond, Virginia, 2000.
Jindal, R.M.; Sidner, R.A.; Hughes, D.; Pescovitz, M.D.;
Leapman, S.B.; Milgrom, M.L.; Lumeng, L.; Filo, R.S.
Metabolic problems in recipients of liver transplants. Clin.
Transplant. 1996, 10, 213-217.
Kasiske, B.L.; Guijarra, C.; Massy, Z.A.; Wiederkehr,
M.R.; Ma, J.Z. Cardiovascular disease after renal transplantation. J. Am. SOC.Nephrol. 1996, 7, 158-165.
Epstein, S.; Shane, E.; Bilezikian, J.P. Organ transplantation and osteoporosis. Curr. Opin. Rheumatol. 1995, 7,
255-261.
Carson, K.L.; Christine, M.H. Medical problems occumng
after orthotopic liver transplantation. Dig. Dis. Sci. 1997,
42, 1666-1674.
Bennett, W. The nephrotoxicity of immunosuppressive
drugs. Clin. Nephrol. 1995. 43 (I), S3-S7.
Shaefer, M.S. Current topics in immunotherapy and the
role of the pharmacist on solid organ transplant service.
Pharmacotherapy 1991, I 1 (6), 136s-141s.
Hilbrands, L.B.; Hoitsma, A.J.; Koene, R.A. Costs of drugs
used after renal transplantation. Transplant Int. 1996,9 (l),
S399 - S402.
Barlow, C.W.; Moon, M.R.; Green, G.R.; Gamberg, P.;
Theodore, J.; Reitz, B.A.; Robbins, R.C. Rabbit antilymphocyte globulin versus QKT3 induction therapy after
heart-lung and lung transplantation: effect on survival,
rejection, infection, and obliterative bronchiolitis. Transplant Int. 2001. 14, 234-239.
Nashan, B.; Moore, R.; Amlot, P.; Schmidt, A.G.;
Abeywickrama, K.; Soulillou, J.P. Randomised trial of
basiliximab versus placebo for control of acute cellular
rejection in renal allograft recipients. Lancet 1997, 350,
1193-1198.
Brethauer, B.; Devine, B.; Jue, M.; Quan, D.; Louie, C.
Cost-benefit analysis of a clinical pharmacists presence on
a post-liver transplant service. Hosp. Pharm. 2000,35 (1 l),
1197-1202.
Vasquez, E.M.; Benedetti, E.; Pollak, R. Ethnic differences in clinical response to corticosteroid treatment of
acute renal allograft rejection. Transplantation 2001, 71,
229 -23 3.
Zetterman, B.K.; Belle, S.H.; Hoofnagle, J.H.; Lawlor,
S.; Wei, Y.; Everhart, J.; Wiesner, R.H.; Lake, J.R. Age
and liver transplantation. Transplantation 1998, 66, 500506.
Johnston, A.; Holt, D.W. Therapeutic drug monitoring of
immunosuppressant drugs. Br. J. Clin. Pharmacol. 1999,
47, 339-350.
Yatscott, R.W.; Aspeslet, L.J. The monitoring of immunosuppressive drugs: A pharmacodynamic approach. Ther.
Drug Monit. 1998, 20, 459-463.
Anaizi, N. Drug interactions involving immunosuppressive
agents. Graft 2001, 4 , 232-247.
Levy, G.A. Long-term immunosuppression and drug
interactions. Liver Transplant 2001, 7, S53-S59.

75

18. Partovi, N.: Chan, W.; Nimmo, C.R. Evaluation of a

patient education program for solid organ transplant
patients. Can. J. Hosp. Phann. 1995, 48 (2), 72-78.
19. Bittar, A.E.; Keitel, E.; Garcia, C.D.; Bruno, R.M.;
Silviera, A.E.; Messias, A.; Garcia, V.D. Patient noncompliance as a cause of late kidney graft failurc. Transplant.
Roc. 1992, 24, 2720-2721.
20. Dunn, J.; Golden, D.; Ran Buren, C.T.; Lewis, R.M.;
Lawen, J.; Kahan, B.D. Causes of graft loss beyond two
years i n the cyclosporine era. Transplantation 19
349-353.
21. Matas, A. Chronic rejection in renal transplants-risk
factors and correlates. Clin. Transplant. 1994, 8, 332-335.
22. Douglas, S.; Blixen, C.; Bartucci, M.R. Relationship
between pretransplant noncompliance and posttransplant
outcoines in renal transplant recipients. J. Transplant
Coord. 1996, 6, 53-58.
23. Beck, D.E.; Fennell, R.S.; Yost. R.L.; Robinson, J.D.;
Geary, D.; Richards, G.A. Evaluation of an educational
programme on compliance with medication regimens in
paediatric patients with renal transplants. J. Pediatr. 1980,
96, 1094.
24. Rodin, G.; Abbey, S . Kidney Transplantation. In
Psychiutric Aspects of Organ Trunsplantation; Craven,
J., Rodin, G.M., Eds.; Oxford University Press: Oxford,
1992; 145- 163.

Swanson. M.A.; Palmeri, P.; Vossler, E D . ; Bartus, S.A.;

Hull, D.; Schweizer, R.T. Noncoinpliance in organ
transplant recipients. Pharmacothcrapy 1991, 11 ( h ) ,
173s-174s.
26. Whiting, J.F.; Martin, I . ; Zavala, E.; Hanto, D. The influence of clinical variables on hospital costs after orthotopic liver transplantation. Surgery 1
27. Kiedar, R.; Katz, P.; Nakache, R. Living again:
Heterogcneous support group for transplant patients and
their families. Transplant. Proc. 2001, 33, 2930-293 1.
28. McCashland, T.M. Posttrnnsplantation care: Role of the
transplant center. Liver
25.

ay, D.K.; Gaber, L.W.;

Gaber, A.Q. Randornizcd double-blind study of standard
versus low-dose OKT? induction therapy i n renal allograft
recipients. Am. J. Kidney Dis. 1993, 22 (I), 36-43.
30. Hcbcrt, M.F.; Ascher, N.L.; Lake, J.R.; Emond, J.; Nikolai,
B.; Linna, J.; Roberts. J.P. Four-year follow-up of
mycophciiolate moreti1 for
recipients. Transplantation
31. Sullivan, S.D.; Garrison, L.P.; Best, J.H. The cost
effectiveness of mycophenolate mofetil i n the first year
after primary cadaveric transplant. U.S. renal transplant
mycophcnolate moreti1 study group. J. Am. Soc. Nephrol.
1997, 8 (lo), 1592 1598.
29.

PHARMACY PRACTICE ISSUES

E!S

nv

Yasmin Khaliq
Rochester, Minnesota, U.S.A.

INTRODUCTION
The Tri-Council Policy Statement is a Canadian document that has been adopted, in 1998, as the standard of
ethical conduct in Canada when performing research
involving human subjects. It reflects the desire to promote
research conducted according to the highest ethical standards. The Policy was developed by three groups: the
Medical Research Council of Canada, the Natural
Sciences and Engineering Research Council of Canada,
and the Social Sciences and Humanities Research
Council of Canada in an effort to aid and support research in Canada. The three councils are aware that
issues regarding ethical conduct are complex and continually evolving and therefore intend to update this document regularly.

The Policy attempts to address the responsibilities of researchers, institutions, and Research Ethics Boards (REBs)
to their subjects. Ethical principles are shared across disciplines such that subjects should expect equal rights as
well as benefits and risks across all fields. The Policy
provides a framework of common procedures by which the
ethics review process may be standardized. The Policy
continues to recognize the diversity of various fields, but
promotes the sharing of general ethical principles. Thus,
this document can lend itself to many areas. The Policy is
not intended to address specific ethical dilemmas but to
provide guiding principles and standards as well as promote thought regarding areas of controversy.
The Policy describes ethics as using morally acceptable means to attain morally acceptable ends. Guiding
principles are found in Table 1. It is critical that the
subjects interests are primary when conducting research,
and that it is understood that benefit and harm are not
viewed by the subject in the same manner as the researcher. Trust by the subject or hope for cure places
876

further emphasis on the need for accuracy and full objective disclosure regarding the proposed research. It is
important that the researcher maintain the right to pursue
knowledge freely but with responsibility. This means ensuring the highest scientific and ethical standards including honesty and accountability. The law regulates research standards with respect to areas such as privacy,
equality, property, and competence. With the continuing
advances in knowledge, technology, and areas of controversy, ethics will likely play a role in defining the law
in the future.
The Policy acknowledges that principles and guidelines require flexibility and exceptions to the rule. There
can be many approaches to an ethical problem and debate
regarding the answers will likely always occur. This will
ensure continued thought and evolution in applying ethical principles to research with humans.
This summary of the Policy is divided into ten sections
similar to the original document: ethics review; free and
informed consent; privacy and confidentiality; conflict of
interest; inclusiodexclusion of populations; aboriginal
peoples; clinical trials; human genetics research; research
involving human gametes, embryos, or fetuses; and human tissue.

ETHICS REVIE
Research requiring ethics review is that which includes
living human subjects as well as human remains, cadavers, tissues, biological fluids, embryos, or fetuses. The
REB is mandated by its institution to approve, reject,
modify, or terminate submitted research proposals to
be conducted within the institution or by its members.
The REB is to have five members: two with knowledge in research, one in ethics, one in law (specifically
biomedical research), and one without affiliation to the
institution who is from the community.
The exposure of a subject to minimal risk is thought to
be equivalent to that encountered in everyday life. Greater
Encyclopedia of Clinical Pharmacy
DOI: 10.1081/E-ECP 120006350
Copyright 0 2003 by Marcel Dekker, Inc. All rights reserved.

Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans

Table 1 Guiding principles for ethics

Respect for human dignity
Respect for free and informed consent
0 Respect for vulnerable persons
0 Respect for privacy and confidentiality
* Respect for justice and inclusiveness
0 Balancing harms and benefits
Minimizing harm
0 Maximizing benefits
0
0

risk requires increased scrutiny of the project. Risk must

also be considered in terms of interventions the patient
would have been exposed to outside of the clinical trial
setting. Risks can be categorized as therapeutic or not, the
latter requiring recognition and consideration by the REB.
The REB must ascertain that any protocol that poses more
than minimal risk to the subject is properly designed to
answer the research question. Compensation considered
greater than that usually available to people is also worth
higher scrutiny to ensure undue incentive is not offered.

The proportionate approach to review is taken, which is

geared toward the principle that the greater the invasiveness or potential risk, the greater the care that should be
taken to review the proposal. Three levels of review are
recommended: 1) full REB review, 2) expedited review
for projects of minimal risk, annual renewals, chart reviews, or projects where REB conditions have been met,
and 3) departmental review. The scope of research that
requires REB review is found in Table 2.
Regular meetings are essential for full REB reviews
with records of minutes documenting all decisions and
dissents with explanations. Decisions must be made
impartially. If desired, an investigator may participate in
the discussion with an opportunity to reply to comments
but cannot be present for the decision process. Protocols
may be resubmitted if rejected. If a decision cannot be
reached initially an appeal board may be utilized; however, appeals following REB decisions are not considered.
When a member of the REB has a personal interest in
the project he or she cannot be present during the decision-making process, although disclosure of conflict and
opportunity to rebut are allowed. All ongoing research
must have a follow-up review proportionate to the level
of risk. Such review often consists of evaluating the
submission at an annual update. Ethics review must be
performed by the appropriate REB of all involved institutions or jurisdictions. Ethics review must be per-

877

formed by the REB of the institution that employs the

researcher(s) as well as by any REB with jurisdiction over
the location of the research.

Free and informed consent is essential prior to participation as well as throughout a study and is usually documented in writing. The need for consent may be altered
or waived when there is minimal risk or low probability
that the action will have negative implications for the
subject, when the research is not possible without alteration or waiver, or when such action does not involve
therapeutic intervention. After participation, additional
information should be provided if possible and appropriate, and consent may be obtained following subject
debriefing. For subjects not proficient in the language of
the consent form, consent may still be obtained provided
an objective competent translator has fully informed
the subject as to the contents of the consent form and
has assisted the subject in participating in discussion of
the study.
Consent must be given fully and with the knowledge
that it can be withdrawn at any time without consequence.
Power and undue influence are of concern particularly in
Table 2 Scope of research that requires REB review
Funding
Subjects

Location

Researchers
Data collection
Publication
Study design

Purpose

Competition

Available or not
Internal or external source
Recruitment internal or
external to institution
Compensation awarded or not
Is subject focus of research?
Within Canada or not
Inside or outside institution
In person or from a
distance (e.g., by mail)
Staff or students
Direct from subjects or
indirect (e.g., chart review)
Planned or not
Observational, experimental,
correlational, or descriptive
Pilot study or full project
For basic or applied knowledge
For teaching or for
acquisition of knowledge
Is a similar project
approved elsewhere?

Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans

878

restricted or dependent subjects and under such circumstances must be judged in context.
REB review is generally necessary for studies of
naturalistic observation. However, studies observing
participants in rallies, demonstrations, or meetings, for
example, do not require REB approval, although issues of
privacy must be considered.

Informing Potential Subjects

Consent may not be obtained without full disclosure of all
information that may affect consent and an opportunity
for discussion. Obtaining consent includes:
Invitation.
Indication of the research purpose.
Identity of the investigator(s).
Nature of the study and time commitment.
Procedures.
Foreseeable harms and benefits.
Alternatives to the research or consequences of
nonparticipation.
Assurance that one is free to not participate or may
decide at a later time or date.
The likelihood of publication of the findings and any
conflicts of interest by the investigators, institution, or
sponsors must be indicated. Other information may be
necessary to include for select projects, such as subject
responsibilities, confidentiality as to subject identity, and
anticipated use of the data.

Competence
Competence refers to a prospective subjects ability to
understand the information provided and its consequences, and make a free and informed decision in
accordance with personal values. If a subject is not
considered competent, a balance must be sought as to
the subjects vulnerability versus the injustice of exclusion from potentially beneficial research. There is a
moral preference to use competent subjects. Subjects not
legally competent should only be asked to participate
when the research question can only be addressed using
the identified group, and the risk is minimal when there
are no direct benefits. The researcher must also demonstrate how the subjects best interests are protected
and the method of obtaining free and informed consent
from an objective third party. If the subject should
become competent during the study, consent must be
obtained for continued participation. Of note, some subjects even if not legally competent may be able to ex-

press their wishes in a meaningful way, e.g., children,

patients with Alzheimers disease. Their dissent precludes participation.

Research in Emergency Health Situations

Research that is to be performed on an individual without
his or her consent is subject to all legislation and regulations as pertinent, and may be allowed by the REB i f
A serious threat exists requiring immediate intervention and research offers a possibility of benefit when
no standard therapy exists.
* Risk is not greater than with standard care or that
benefits justify risk.
* Third party authorization cannot be secured despite
diligent efforts.
No prior directive by the subject is known to exist.
This is an uncommon situation that may occur if a
subject has lost consciousness or competence. Additional
safeguards to protect the subjects rights and interests
may include additional scientific/medical/REB consultation, procedures to identify subjects in advance to
obtain consent prior to occurrence of an emergent situation, monitoring procedures by safety boards, and
careful REB review for assessment of harms and benefits
of participation.

The need for privacy when participating in research is

based upon a subjects dignity and autonomy and thus
warrants respect. As a result, all information regarding a
research subject must be kept confidential. The researcher
has a duty not to share any information without a subjects
free and informed consent. Respect for privacy is an internationally recognized ethical standard and is reflected
in Canadian law as a constitutional right. However, there
are some circumstances where public health and safety
require protection and such privacy may be lost, e.g.,
child abuse, sexually transmitted diseases. The REB can
play an important role in assessing the balance between the
need for research versus invasion of privacy, thus protecting individuals from harm as a result of unauthorized
use of personal information.

Personal interviews and Data Collection

REB approval is required for interviews and documentation of personal information by research subjects, and free

Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans

and informed consent is necessary. REB approval is not

necessary for access to public information or materials.
REB approval requires consideration of the purpose and
type of data, limits on its use, safeguards for confidentiality, modes of observation that may identify the subject,
anticipated secondary uses of the data, and anticipated
linkage with other data. Subjects must be informed who
will have access to any identifying information, e.g., government or agencies, research sponsors, or the REB, and
must provide consent for such access to occur.

econdary Use of Data

When data are used for purposes other than the research
for which they were collected, REB approval must be
sought if individuals are identifiable. Researchers must
demonstrate that knowledge of the subjects identities is
necessary for the current use, that confidentiality will be
maintained and that the involved individuals have not
objected. If deemed appropriate, the REB may require
either informed consent from those who contributed the
data, an appropriate strategy for informing subjects, or
consultation with representatives of those who contributed
the data. REB approval is also required for situations
when a researcher wishes to contact individuals to whom
data refers. Linkage of databases where research subjects
may be identifiable requires REB approval.

With increasing concern for conflicts of interest, such

issues must be identified by the researcher, institution, and
REB for professionalism, to maintain public trust, and for
accountability. All conflicts, whether actual, perceived, or
potential, must be disclosed to the REB and addressed.
They must also be disclosed to the subject during consent.
For the REB to identify and best address conflicts, it
should be provided with details of the research project,
budgets, commercial interests, consultative relationships,
and other information as relevant. REB members must
withdraw from the discussion and decision-making when
their own research is under review. Methods to address
and resolve conflicts must be developed. REBs must be
given the authority and financial and administrative
independence from the institution to fulfill their duties.

ULATlON
Choice of inclusion into research studies should follow
the principle of distributive justice, i.e., no member in

879

society should bear an unfair share, nor be unfairly

excluded in research participation. Vulnerable subjects
have been excluded to avoid the issue of exploitation yet
have thus also been denied the potential benefits of
participation. Researchers shall not exclude potential
research subjects based on culture, religion, race, mental
or physical disability, sexual orientation, ethnicity, gender, or age, unless a valid reason applies. Women must
not be excluded on the basis of gender or reproductive
capacity although harms and benefits must be considered. Incompetent subjects must not be excluded from
research that may be beneficial to themselves or the group
they represent.

O R I ~ I N A LPEOPLES
The aboriginal peoples are recognized as having a unique
culture and history and perspective in life. Research
regarding their customs and community has in some cases
been respectful; however, there has also been inaccurate,
insensitive research conducted causing stigmatization and
thus apprehension with respect to future research proposals. Thought must be given to language differences
and different ideas about public and private life. Involvement of academic or community members from this group
is essential for appropriate ethics review. The needs and
concerns of the people along with respect for their property, culture, traditions, and unique viewpoints must be
considered by investigators. The community must also be
given the opportunity to respond to findings prior to completion of research reports.

Clinical trials are addressed in the context of biomedical

research. Research can include case studies, cohort studies, randomized controlled trials, or multicenter trials.
While the methodology of these studies is greatly varied,
the guiding ethical principles and procedures remain the
same. To begin research there must be clinical equipoise,
or a reasonable uncertainty warranting pursuit of an
answer. Such an approach should ensure bias is minimized in all therapeutic arms and that participation is not
considered disadvantageous. Research is generally categorized into four phases as found in Table 3.
Research with new medical devices must be carefully
evaluated to ensure free and informed consent can be
obtained. REBs must aid researchers to prevent conflicts
of interest. This could be concerning subject selection or

Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans

880

Table 3 Phases of research

Phase

Dose-finding studies of new

medications to determine
acute toxicity.
Healthy subjects or patients.

I1

Determination of short-term
pharmacologic toxicity,
some degree of efficacy.
Patients with specific diseases.
Determination of pharmacologic
efficacy to increase survival or
quality of life, some toxicity.
Patients with specific diseases.
Determination of long-term efficacy
and toxicity of marketed drugs.
Postmarketing surveillance studies.

I11

IV

Comments

escription

These studies warrant close REB review with continuous

monitoring independent of the trial sponsor. This is especially
important as more of these trials include patients refractory to
standard therapy, and with the increasing number of new medications.
Unexpected adverse events are a major concern.
Phase I and I1 studies must be carefully examined for free and
informed consent procedures. An independent continuous review
may be necessary.
Phase I1 and I11 often include placebos to assess toxicity of a
new agent. Use of placebo must be justified and minimization of
harm ensured.
These studies are often conducted in private practice for postmarketing
with a per-capita fee paid to assess side effects and patient acceptance.
Such payments can create bias. REBs must assess the science and ethics
of these studies as much as with the other phases.

payment by sponsors to the investigators. Safety standards of new devices must be assured. Continued provision of therapy beyond the trial termination must also
be examined.
If research is to be used for regulatory approval of a
drug, the International Conference on Harmonization
(ICH) guidelines that have been adopted by Canada must
be followed. Budgets must be evaluated to ensure no
conflicts of interest exist. Placebo-controlled studies are
not considered acceptable when effective standard therapies or interventions are available. Investigators must
inform subjects as to why placebos are necessary when
used, and, if any treatment is to be withdrawn and the
associated impact. Although sponsors may obtain preliminary data for analysis, final analysis and interpretation
should be by the researchers to ensure the accuracy and
integrity of the work.

TICS RESEARCH
The study of genes that determine human traits is very
topical and not without controversy. Identification of
genes that comprise the human genome, their function,
and their ability to predict disease or a predisposition to
disease is central to this research. However, because
genetic material in one individual is shared by biological relatives, privacy and confidentiality affect not
just the individual who may wish to consent to research
participation. The effects of such research and how

information will be used and interpreted are unknown,

requiring prudence in pursuing research in genetics.
An individual may feel hisher identity and self-worth
are threatened, not to mention any associated stigma
that may occur toward the group to which the individual belongs.
Important considerations are as follows:
Consent is critical in genetics research, and concern
that the individuals family may be coercive and that
information may affect other members in the family
should be considered.
Results of genetic tests must be protected from any
third party access unless free and informed consent
is given. DNA banking allows family and clinical
information as well as genetic material to be a resource for other researchers; however, removal of
the subjects and familys identity is important. Any
potential harm must be disclosed to the REB as well
as how it will be dealt with. For example, information
about an individuals susceptibility to disease may
provoke anxiety, particularly if effective therapy or
prevention is not available.
Genetic counseling must be available for subjects as
needed. The issue of cultural differences in the perception of this research must be accounted for.
Gene alteration, including gene therapy, using human
germline cells or embryos, is not considered ethically
acceptable. Gene alteration done for therapeutic reasons and using human somatic cells may be considered.

Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans

Irreversibility and lack of long-term follow-up suggest

the use of this technology should be with care.
Genetic research should be performed for the pursuit
of knowledge or therapeutic benefits in disease, not
to enhance or improve a population by cosmetic
manipulation.
Banking or storing of genetic material may yield
benefit or harm. A defined term of storage and provisions for confidentiality and anonymity including
for the future must be addressed.
The likelihood of commercial use of genetic material
and information must be discussed and consent
obtained.

There are complex concerns as to the possible harm to

the embryo or fetus as well as the respect they deserve,
and a cautious and controlled approach to such research
is essential.
The human reproductive cells (ova and sperm) may be
used for research provided free and informed consent is
given. Use of gametes derived from cadavers is prohibited
and use of gametes from fetuses or individuals unable to
consent for themselves is deemed unacceptable. The use
of gametes acquired by commercial transaction is considered unethical. Creation of hybrid individuals (e.g., a
mix of human and animal gametes or transfer of somatic
or germ cell nuclei between cells of humans and other
species) is unethical and does not show consideration for
human life and dignity.
It is not ethical to create human embryos specifically for research. If an embryo was created for reproduction but is no longer needed, it may be used for
research if 1) consent is given, 2) no commercial transaction took place, 3j no genetic alteration of the gametes or embryo occurred, 4) manipulations not directed to normal development are not used for continued
pregnancy, 5 ) that the research occurs within 14 days
of the creation of the embryo by joining the gametes.
It is not ethical to participate in research cloning human beings (ectogenesis).
With maternal consent, research may be undertaken in
utero for fetuses with genetic or congenital disorders. Use
of fetal tissue cannot affect a womans decision regarding
continuation of her pregnancy, nor can fetal tissue be directed for use in specific individuals as the fetus deserves
respect as a potential person not just a source of tissue.

881

Human tissue should be respected to maintain the dignity of the donor. Canadian law allows competent persons
to donate, although not sell, human tissue for research.
Concerns for confidentiality of tissue identity has led to
the following categorization:

1. Identifiable tissue: donor known.

2. Traceable tissue: by database.
3. Anonymous or anonymized tissue: donor identity
stripped.
The REB must consider the likelihood of the traceability of tissue in a research project with respect to
privacy and confidentiality.
Collection of human tissue for use in research requires
the researcher to demonstrate to the REB that free and
informed consent will be obtained from competent
donors, or from an authorized third party for incompetent
donors or deceased donors without advance directive
regarding the topic. Minimally, researchers must provide
the research purpose; the type, location, and amount of
tissue to be taken; the manner of acquiring the tissue with
respect to safety and invasiveness of the procedure; the
uses of the tissue; and how its use could affect privacy.
Consent is also necessary for use of previously collected
tissues when identification is possible.

The Tri-Council Policy strongly promotes research and

attempts to provide guidance regarding ethical principles that ensure an individuals rights and interests are
protected. Rapidly advancing knowledge and technology
present us with new research issues and controversies
that will require continual review of ethical guidelines
and much opportunity for thought and debate regarding
future research.

Tri-Council Policy Statement: Ethical Conduct for Research

Involving Human Subjects; Public Works and Government
Services, Canada, 1998, Catalogue No: MR21-1W1998E.
ISBN 0-662-27121-1.
Also found on the World Wide Web at: http:l/www.nserc.cal
programs/ethics/english/policy.htm(accessed October 2000).

PROFESSIONAL ORGAN lZATl0 NS

Pat Murray
Royal Edinburgh Hospital, Edinbwgh, U.K.

The UK Clinical Pharmacy Association (UKCPA) was

launched in 1981 and since then membership has risen to
over 2000 members. The success of UKCPA reflects the
fact that the organization has been a fundamental part of
the recognition of clinical pharmacy as part of the
mainstream of pharmacy practice. As envisaged by the
founders of UKCPA, clinical pharmacy is not a specialty
within pharmacy but a discipline that is practiced by all
pharmacists working with patients. Pharmaceutical care
developments in all areas, including Primary Care, are
now showing the relevance of the examples of practice
that UKCPA has promoted. UKCPA members activities
have also had an influence on the Schools of Pharmacy to
embrace clinical pharmacy within the core curriculum
and to teach the skills by problem-based learning. The
UKCPA workshops have been a major part of the wellknown high quality conferences of which the Association
is proud. The UKCPA has developed an organizational
structure and a team approach in its work. Access to
UKCPA has been further enhanced following the launch
of our Website last year. (www.ukcpa.org).
Following is a description of the organization.

USlN

AN

The Business Group (BMG) focuses on ensuring the

Association runs smoothly and efficiently. UKCPA is
regularly invited to comment on new professional development proposals and it is the role of the BMG to
respond on behalf of UKCPA, taking into account comments received from consultation.
The success of recruiting new members is assigned to
the Membership and Marketing Committee.
This committee has set three main goals for the
forthcoming year:
a

To maintain and increase the current membership by

highlighting the opportunities that UKCPA can offer.

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To identify and co-operate with other pharmacy

groups in order for mutually beneficial collaborations
to take place.
* To strengthen and increase the corporate membership.
UKCPA can only benefit if enthusiastic pharmacists
are attracted to the organization. In return it can offer an
exciting arena for such people to learn, participate and
meet other pharmacists contributing to the profession.
Clinical pharmacy now envelops all strands of the profession and it is the role of the Marketing and Membership Committee to publicize this information.
UKCPA publishes a newsletter -In Practice a range
of practice guides and workshop support material. The
two annual symposia attract over one hundred submissions of research and practice development work and the
conferences provide a highly interactive format and polished performances. Conference presentations (oral communications and posters) are published as short papers
or abstracts in the UKCPA official journal Pharmacy
World and Science. All this is the remit of the Publications Committee.
Handling UKCPA conference communications and
the adjudication process requires a scrupulous process to
make it work for members. UKCPA has developed a
housestyle and is a transparent process of adjudication
and feedback to assure the final quality of work presented and published. This applies equally to the adjudication process for the four industry sponsored awards,
AstraZeneca Travelling Fellowship Award, the four
GlaxoSmithKline Poster Awards, the Pharmacia Pharmacoeconomics Award and the Wyeth Education and Training Award. New awards for 2002 are Unichem ComrnunityPrimary Care Pharmacy Award, Napp Palliative
Care Award and the Merck Pharmaceuticals for Medicines Management Award.
The UKCPA Office plays an important role in helping
the association organize many of the UKCPA events.
It is the Education Programming Committee who have
the responsibility of identifying and implementing the
educational content.

883

UK Clinical Pharmacy Association

884

The committee, which is made up of the Chairs of six

Practice Interest Groups and four General Committee
members, oversees the main educational events described
in the programme. It has a challenging job in co-ordinating the main symposia while seeking to be visionary,
to ensure the content of future symposia will attract participants some 12 months in advance of the planned event.
There is much to do with the planning, implementation and review of each programme, which attracts up to
350 participants.
Practice Interest Groups reflect the broad range of
interest and experience among members and provide a
network of support among members by maintaining a data
base of members and their area of expertise. Each group
regularly contributes to In Practice, reviewing current
researcNdevelopments in their field and training opportunities. The groups comprise:
Care of the Elderly
Critical Care
Education and Training
Medicines Management in Primary Care
Quality Assurance
Surgery and Theatres
Infection Management
Each group sends a message.

Care of the Elderly

The aim of the group is to enhance the pharmaceutical
care of elderly people, within both primary and secondary
care. It does this by facilitating the continuing education
and networking of its members.
The Group organizes study days, mini-symposia and
workshops. Topics have included the pharmaceutical care
of patients with stroke, dementia and osteoporosis plus a
day on ophthalmological problems.

Critical Care Group

The Group provides support for all pharmacists who have
an interest in the field of critical care, which includes
intensive care, high dependency and coronary care. The
groups core objectives are:
To continue to provide regular, objective and high
quality educational meetings.
To provide supportive documentation, especially for
those new to the field.
To promote the role of the critical care pharmacist
within a multi-disciplinary setting through a closer
liaison with the Intensive Care Society.

* To push forward the debate on specialist pharmacists.

To promote and support research within the field of
critical care.
ducation and Training
Training is a component of most jobs: many people are
expected to teach others, but many have had little
guidance on how to perform this key activity successfully.
The Education and Training Group of UKCPA aims to
share and promote good practice in the field, and to
support these individuals in their role.
Training sessions are organized, either as part of the full
UKCPA symposia, or as stand alone days. For example, a
recent study day on the topical issue of competency-based
training was held. The group has also written a guide for
good practice in education and training, as a short practical
aide memoir for consideration when planning an educational event. Commissioned resource guides in key areas
such as teaching communication skills and assessment
have also been published.

ement in Primary
Care Group
The Medicines Management in Primary Care Group was
formed four years ago to provide support for the increasing number of pharmacists developing a clinical
role in Primary Health Care Teams. The objectives are to:
Provide education and training for pharmacists to develop clinical pharmacy in primary care.
Facilitate liaison between primary and secondary
care pharmacists.
Encourage communication between all pharmacists
working in this area by providing a forum for exchange of ideas.
Promote innovation and encourage practically applicable research.
Recent workshops have included patient perspectives,
therapeutic topics including cardiovascular and gastrointestinal systems, medicine resource management, medication review and pharmacist-led clinics.

The QA group was formed in the early days of UKCPA

when intervention monitoring was the flavor. Since then,
the Groups focus has broadened to address a whole range

UK Clinical Pharmacy ~ ~ ~ s o ~ i a t ~ o ~

of issues which are general to all clinical pharmacists,

managers including those in Primary Care.
Recent examples of workshop topics at our two annual UKCPA symposia included sessions on compliance/
concordance, PILs, off-label use of medicines, medicalion errors and ADR reporting. For the future, clinical
governance and all its implications are high on the
agenda and, to paraphrase the definition, we intend to
hclp.. . .create an environment in which pharmaceutical
care will flourish.

The Surgery and Theatres Pharmacists Croup aims to

cnahle pharmacists world-wide to network and share best
practice thereby furthering the role of pharmacy in these
fields of medical practice. A system has been developed
to allow pharmacists to share guidelines and protocols
through a Resource Centre. Access to the Groups services are via the internet. The Group has its own website
at www.users.globalnet.co.uk/~ph(~ward/sat~.htin.
Other services provided are an interactive Newsgroup
that allows members to canvas views of other members,
a bibliography of key references, an on-line newsletter,
links to over 180 related sites, and a network of subgroups. The Newslctter reviews initiatives that pharma-

885

cists have introduced successfully. It also reviews the

surgical and anaesthetic literature.
The Group also has a directory of members that allows
pharmacists to contact specialists in a particular area for
advice or information.
The Group would like to see a member from all 700 +
hospitals within the UK ensuring all hospitals have access
to best practice.

The Infection Management Group is a new group formed

this year.
UKCPA has links with the European Society of
Clinical Pharmacy. This has afforded opportunities for
our members to network beyond the UK with opportunities for some industry sponsored award winners to
present posters at an ESCP meeting on an annual basis.
This link has enriched our symposia by ESCP member
attendance or ESCP contributed workshops.
In early 2000 the General Committee met to prepare a
UKCPA business plan for the next few years. Use this
opportunity to influence future activities of the Association through scnding your comments/suggcstions to:
UKCPA, Alpha House, Countesthorpe Road, Wigston,
Leicestershirc, LE 18 4PJ. E-mail: pkenncdy @ukcpa.
u-net.com. Web site: www.ukcpa.org.

PROFESSIONAL RESOURCES

Roger L. Williams
US. Pharmacopeia, Rockville, Maryland, U.S.A.

Standards established by the United States Pharmacopeia

(USP) are accepted worldwide as the highest assurance of
the quality of medicines and other products used to improve the health of the public. We discuss the development of the publication and the organization, and its
current and future initiatives toward promotion of worldwide health.

The first Pharmacopoeia of the United States, published in

1820 by USP, was an important milestone in American
medicine and pharmacy. It was a compendium of about
217 of the best understood drugs and drug preparations and
a lexicon of standard drug names. Three medical visionaries-Lyman Spalding and Samuel Mitchill from New
York and Jacob Bigelow from Boston-were largely responsible for this work. They intended the Pharmacopeia to
accomplish a degree of drug standardization and to facilitate communication between physicians and pharmacists.
Today, USP publishes more than 3400 official standards
monographs for drugs and other healthcare products.

According to Roger L. Williams, M.D., USPs Executive

Vice-president and Chief Executive Officer, USP pursues
its mission to promote public health through multifaceted activities:

* Establishing and disseminating officially recognized

standards of quality for therapeutic products.
* Collecting information from practitioners to help reduce and prevent medication errors.
* Educating healthcare professionals and patients on
the appropriate use of therapeutics and improving the
health of special populations worldwide.

886

As a pharmacopeial organization, USP has certain unique

characteristics:
Non-governmental with statutory recognition: USP
is the worlds leading nongovernmental pharmacopeia. According to the Federal Food, Drug,
and Cosmetic Act, USP standards are enforceable by the Food and Drug Administration
(FDA) for all drugs manufactured and sold in
or imported into the United States. The standards
are also officially recognized in many other
countries.
Volunteers lead the way: USP achieves its goals
through the contributions of volunteer experts representing pharmacy, medicine, and other healthcare professions, as well as science, academia, the
U.S. government, the pharmaceutical industry,
and consumer organizations. Volunteers constitute
USPs membership, Board of Trustees, and scientific decision-making committees. They are supported by a staff of over 350.
Standards set by a participatory process: USP
standards are developed by an exceptional process
of public involvement. The process gives those
who manufacture, administer, regulate, and use
therapeutic products the opportunity to comment
on the development and revision of standards used
to measure the quality of these products.
Role that expands beyond standards: Unlike most
of the worlds major pharmacopeias, USPs role
is not limited to the establishment of written
and chemical pharmacopeial standards. USP also
helps to monitor and prevent medication error
problems through reporting programs for healthcare professionals. The valuable information and
feedback obtained through these programs enables USP to enhance the accuracy and utility of
its standards.

Encyclopedia of Clinical Pharmacy

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2003 by Marcel Dekker, Inc. All rights reserved.

887

United States Pharmacopeia

USPs direction and priorities are determined by more

than 400 credentialed members through resolutions that
they vote to adopt at quinquennial meetings of the USP
Convention. Members also elect the USP Convention
officers, Board of Trustees, and Council of Experts-the
scientific decision-making body.
USP membership is on a 5-year cycle. Within each
membership category, eligible organizations (Fig. 1) are
invited to appoint their representatives. Membership
composition is determined to ensure suitable representation of those sections of the healthcare system that are
impacted by, and in turn impact, USPs activities. D.
Craig Brater, M.D., Dean of the Indiana University
School of Medicine, is the USP Convention President for
2000-2005.
USPs Board of Trustees is elected for a 5-year term
and has fiduciary responsibility for the organization.
Larry L. Braden, R.Ph., is the Chairperson of the 20022003 USP Board. A complete list of Board members is
available at www.usp.org.

Sixty-two scientific experts serve on the Council of

Experts and chair expert committees, which are responsible for making scientific decisions. Visit www.usp.org
for a list of USPs 2000-2005 expert committees and
chairpersons. The Council of Experts is chaired by Roger L. Williams, M.D., USPs Executive Vice-President
and CEO.

CTS

USP-NF

Official pharmaceutical standards are published in a

single volume combination of the United States Pharmacopeia (USP) and the National Formulary (NF),commonly referred to as USP-NF. This authoritative reference
provides pharmaceutical standards of identity, strength,
quality, purity, packaging, storage, and labeling. Monographs and general chapters relating to drugs for human as
well as veterinary use are found in USP, and those relating
to excipients are found in the N F . Monographs for bota-

Man~~act~res,

Associations

Pharmacopeias

Fig. 1 USP convention membership.

with permission.

a2002

The United States Pharmacopeial Convention, Inc. All rights reserved. Used

888

United States Pharrnacopeia

nicals used as dietary supplements and having a FDAapproved or USP-accepted use are found in the USP.
Monographs for botanicals recommended for official
adoption by the USP Council of Experts and for other
botanicals with no accepted or approved use, but with no
safety concerns, are found in the NF. Monographs for
nutritional supplements-vitamins and minerals-appear
in a separate section.
USP-NF monographs include assays and various analytical methods-identification,
dissolution, content uniformity, etc. USP-NF also provides guidance and standards on biotechnology, radiopharmaceuticals, pharmacy
compounding, and pharmaceutical waters. General chapters outline requirements for microbiological, biological,
chemical, and physical tests and assays.
USP-NF is available in four formats-a
thumb-indexed hardcover, online, a CD for WindowsE, and an
Intra net version.

Fig. 2 USP standards development.

with permission.

c 2000

Statutory recognition
In the United States, the Federal Food, Drug, and Cosmetic (FD&C) Act affords recognition to USP and NF as
official compendia and to the articles contained therein.
According to sections 201(g) and (h) of this Act, the
terms drug and device include articles recognized
in the official USP or NF or any supplement to any of
them. Section 501(b) provides that a drug is adulterated
if it does not conform to USP standards for strength,
quality, and purity. Section 502(g) requires a drug to
conform to packaging and labeling requirements in the
official compendium.
The Dietary Supplement Health and Education Act
of 1994 (DSHEA) and the Food and Drug Administration Modernization Act of 1997 (FDAMA) extended the
utilization of the USP and NF by amending the FD&C
Act. Section 403(s)(2)(D) of the FD&C Act provides

The United States Pharmacopeial Convention, Inc. All rights reserved. Used

8S9

United States Pharmaeopeia

that a dietary supplement represented as conforming to

the specifications of an official compendium shall be
deemed misbranded if it fails to do so.
Pharmacopeial Forum
Pharmacopeial Forum (PFj is the journal through which
USP institutes the public review and comment process for
standards development and revision (see Fig. 2 for a
process overview). Proposed changes to official USP-NF
standards are published in PF so that all interested parties
may review them. offer their opinions, and prepare for
their impact. PF also provides notice of binding revisions
to the official standards. It includes authoritative scientific articles and comments on current pharmaceutical industry issues.

USP establishes and validates chemical Reference

Standards that help to ensure pharmaceutical quality.
USP Reference Standards are used to conduct the official
tests for product identity, strength, quality, and purity
specified in USP-NF. Potential Reference Standards are

rigorously and collaboratively tested in USP, FDA. and

industry laboratories (see Fig. 3). USP currently has
more than 1250 pharmaceutical Reference Standardsone of the worlds largest collections-and
about 500
new items under development.

edMARxSM
MedMARx is an effective, proactive solution to the
serious and costly problem of medication errors in the
United States. It is an Internet-accessible, anonymous,
national database through which hospitals can report,
track, and analyze medication errors to help prevent their
recurrence. Errors are reported to MedMARx in a standardized format and categorized according to a nationally
recognized index. This allows facilities to share information anonymously and learn from others errors and
preventive strategies. Participating facilities also receive
national medication error alerts and reports on key error
trends. MedMARx is backed by more than 30 years of
USP experience in operating voluntary medication error
and drug product problem reporting programs for healthcare professionals.

plement Verification

In 2001, USP created the Dietary Supplement Verification

Program (DSVP) to help inform and safeguard the
growing number of consumers who use dietary supplements. The program responds to the need to assure the
public that dietary supplement products contain the
ingredients stated on the product label. If a product
submitted to DSVP meets USPs rigorous standards, it
will be awarded the DSVP verification mark. The mark
helps assure consumers, healthcare professionals and
supplement retailers that a product:
Compilation of collaborative study is sent to the USP

Fig. 3 Reference standards process. C. The United States

Pharmacopeial Convention, Inc. All rights reserved. Used with
permission.

Contains the declared ingredients on the product label.

Contains the amount or strength of ingredients declared on the product label.
Meets requirements for limits on potential contaminants.
Has been manufactured properly by complying with
USP and proposed FDA standards for good manufacturing practices (GMPs).

ew Mon
Currently, there are no public standards for about 35%
of drugs in the U.S. market. USP seeks to develop public

United States Pharmaeopeia

890

quality standards for all therapeutic products in the

market, especially for the top 200 prescribed drug products and active pharmaceutical ingredients. Increased
cooperation is being obtained from the pharmaceutical
industry for a program to prepare and publish proposed
standards monographs for newly approved drugs and
drug products six years before patent expires.

USP, through its participation in the Pharmacopeial Discussion Group (PDC), is working closely with the European and Japanese Pharmacopoeias to explore the harmonization of pharniacopeial standards for cxcipicnts,
microbiological testing, general methods of analysis, and
methods of analysis for biotechnology-derived products.
Several general test methods have already been harmonized. USP serves on Quality Expert Working Groups at
the International Conference on Harmonization (ICH). It
also works through the Pan American Health Organization and with individual countries around the world to
ensure drug quality.

The USP Convention membership, at its April 2000 Quinquennial Meeting, adopted reyolutions directing USP to
explore in the ncxt 5 years:
e

The impact of applied genomics on drug discovery and

development and therapeutic applications.

Approaches to assure equivalence of complex active ingredients, including botanicals and dietary
supplements.
The application of modern biopharmaceutic principles
to assure the equivalent performance of immediateand modified-release drug products.
Compounded drug formulations for special populations.
Packaging, labeling, nomenclature, and dosage form
characteristics for medicines to reduce medication
errors.
Standardized imprint coding for all solid oral dosage
forms.
Methods research on botanical ingredients.
Compounding guidelines for veterinary extra-label use
of medications.
Education and training programs for health professionals to support the appropriate use of the USP-NF
and expand its use.

The USP Convention membership meets once cvery 5

years to discuss the areas of healthcarc in which USP
should bc involved. These quinquennial meetings help
to define USPs strategic focus and priorities for a 5year period.
USP conducts open meetings as needed to invite the
views of interested parties on issues of current significance in the pharmaceutical industry and the nature of
USPs involvement with these issues. Notices of open
meetings are posted on USPs web site at www.usp.org.

PHARMACY PRACTICE ISSUES

rent
atric
Gene
University at Buffalo, Buffalo, New York, U.S.A.

As early as 1982, the Centers for Disease Control and

Prevention (CDC) began issuing precautions for the
handling and care of laboratory specimens from patients
infected with the human immunodeficiency virus (HIV1). The goal was to minimize the risk of exposure to
infectious blood and blood-containing body fluids. Although it was previously recognized that blood and
hypodermic needles posed a significant risk to the
healthcare worker, this issue moved to the forefront of
clinical practice with the recognition of the HIV/AIDS
epidemic, when it became clear that healthcare workers
would be at increased risk for exposure to HIV-1 and
other blood-borne pathogens. In 1987, the CDC issued
guidelines that were designed to minimize the risk of
HIV- 1 transmission in the healthcare setting. These
guidelines have since become known as the universal
precautions.] Universal precautions became mandatory in 1991 with the passage of the Occupational
Safety and Health Administration (OSHA) Blood-Borne
Pathogens Standard, which required healthcare employers to establish, at minimum, an exposure control plan
and offer training to employee^.[^-^] Since their
introduction, there have been numerous modifications
of these guidelines by the CDC, Public Health Service
(PHS), and OSHA. These modifications incorporate
new scientific knowledge and address additional concerns that have arisen in the area of occupational
exposure^.[^-'^] Recently, the Public Health Service
interagency working group, comprised of members of
the CDC, Food and Drug Administration (FDA), and
NIH, issued updated guidelines that consolidate recommendations regarding the management of healthcare workers who have experienced occupational exposure to blood and other body fluids that may contain
HIV .[I
O1

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Universal precautions are intended to supplement standard

infection control procedures and rely on the use of protective barriers such as gloves, goggles, facemasks, as well
as proper safety conduct, such as hand washing, avoiding
recapping of needles, and proper disposal of medical waste.
The concept of universal precautions is based on the
underlying assumption that blood and certain body fluids
from all patients is potentially infectious for HIV, hepatitis
B virus (HBV), hepatitis C virus (HCV), methicillin-resistant Staphylococcus aweus (MRSA), or any other bloodborne pathogen. In this context, potentially infectious body
fluids include: cerebrospinal fluid, vaginal secretions, semen, pleural fluid, peritoneal fluid, pericardial fluid, and
amniotic fluid.,01 Universal precautions do not apply to
body substances such as feces, sweat, tears, urine, human
breast milk, vomitus, nasal secretions, sputum, or saliva
unless visibly bloody; but this in no way lessens the need
for practicing standard infection control procedures.01
The term healthcare worker is very broad and refers to
any person whose activities involve contact with patients or
with blood or other body fluids from patients in a healthcare ~ e t t i n g . [ ~ ~An~ ~exposure
~~~
that places a healthcare worker at risk for HIV or other blood-borne pathogens
and requires consideration for post-exposure prophylaxis is
defined as any percutaneous injury, contact with mucous
membrane or nonintact skin (i.e., chapped, abraded, or skin
with dermatitis), or contact with intact skin when the
duration of contact is prolonged (i.e., several minutes or
greater) or extensive with blood, tissue, or body fluids.

Given the HIV/AIDS epidemic, in addition to the increase

in other viral infections such as HBV and HCV, the need

891

892

to adopt some form of protective measures, and thus the

rationale for universal precautions, is clear. It has been
suggested that there are three main reasons for applying
universal precautions.["] The first stems from the inability to test and identify every patient to discern if they
are infectious. Therefore, it is most prudent to assume that
all patients are infectious and thus act accordingly. The
second reason is psychological in nature and takes into
account human behavior and performance regarding
identification and labeling practices. Lastly, there are administrative and legal reasons that embrace OSHA's
mandate for employers to provide a safe working environment for employees.

Universal Precautions and Post-exposure Prophylaxis for HIV

Table 1 Factors associated with an increased or decreased risk

of occupational HIV transmission following an exposure
Increased risk
of transmission
Exposure to large quantity
of blood
Exposure occured during
placement of needle into
artery or vein
Exposure occurred during
invasive procedure
Deep injury
Visible blood on needle/object
Source with increased viral load

Decreased risk
of transmission
Use of gloves
Mucous membrane
exposure
Prompt initiation of
post-exposure prophylaxis
Intact skin exposure

TRANSMISSION RISK AND lEPlDEMlOL

The true risk of transmission following occupational exposure is difficult to determine due to the high rate of
underreporting of exposures and the underlying risk of
healthcare workers being infected with HIV- 1 outside of
the workplace. However, one prospective study determined that a percutaneous exposure to HIV-infected
blood is associated with a 0.3% risk of transmission."21
The risk is lower after a mucous membrane exposure at
0.09%.[121The risk associated with HIV transmission
after skin exposure has not been precisely defined, because presently, no HCW enrolled in any prospective
study has seroconverted following an isolated skin exposure: nonetheless, the risk is thought to be less than
for mucous membrane e ~ p o s u r e . " ~ The
" ~ ~ risk of HIV
transmission following exposure to bodily fluids other
than blood, such as cerebrospinal fluid, vaginal secretions, semen, pleural fluid, peritoneal fluid, pericardial
fluid, and amniotic fluid is not presently known. Factors
that increase or decrease the risk of HIV transmission
following an occupational exposure are listed in Table 1.
The increased risk resulting from exposure to blood
from terminally ill AIDS patients likely reflects an
increased viral
In these instances, it has been
suggested that the risk of HIV transmission exceeds
0.3%, but the practical utility of using HIV titers from
source patients as a marker for transmission is unknown,
and a low HIV titer does not rule out the possibility of
HIV tran~mission."~]
As of June 1997, documented HIV seroconversion
temporally associated with occupational HIV exposure
was reported in 52 healthcare workers.["] Forty-seven
cases involved exposure to HIV-infected blood, 45 exposures were percutaneous in nature, and most involved
a hollow-bore needle (91%)."01 The remaining five
cases involved exposure to HIV-infected bloody body

fluid, concentrated virus in laboratory, and one case was

unspecified. This data may not represent the true number of occupational HIV infections, because not all
workers are evaluated for HIV infection following occupational exposure, not all workers with occupational exposurehnfection are reported, and an estimated
40% or more of needlestick injuries may go unreported."s-171 Needlestick injuries, whether a consequence of
recapping or improper disposal techniques, continue to be
a frequent and important mode of HIV e x p ~ s u r e . " ~A]
large prospective surveillance study, the CDC Cooperative Needlestick Study, found more than 80% of all
exposures were related to needlestick injuries.[18] Surveillance data indicates laboratory technicians, followed
by nurses and physicians, represent the most common
occupations associated with occupational HIV transmiss i ~ n . " ~Some
]
have argued that universal precautions
may not significantly decrease exposure, as a glove cannot prevent a needlestick injury. However, there is evidence that despite the ability of needles to pass through
latex gloves, there may be a substantially lower blood
innocula associated with the use of latex gloves, perhaps suggestive of a reduced likelihood of occupational infection.[20'2']

POST-EXPOSURE PROPHYLAXIS FOR HIV

Post-exposure prophylaxis, or the administration of pharmacological agents with the intent of preventing occupational HIV transmission after exposure, may be useful
in certain circumstances. The decision to use post-exposure prophylaxis is complex and depends on a number of
important factors, which should be evaluated on an individual, case-by-case basis. This decision should take

Universal Precautions and ~ o s t - ~ x ~ o ~u r~e o ~ ~for~ l a x ~

into account the nature of the exposure, including volume

of blood or body fluid involved. source of exposure and
risk of transmission, time between exposure and start of
post-exposure prophylaxis, and documented efficacy of
post-exposure prophylaxis. The potential benefits of postexposure prophylaxis must be weighed against the PO-

893

tential hazards in deciding treatment duration, potential

adverse effects of antiretroviral agents. viral resistance,
and pregnancy. Fig. 1 outlines general considerations and
procedures that should be followed after an occupational
exposure. Note that the algorithm is a suggested approach
and does not represent all possible scenarios; each ex-

soap and water, flush m u w u

~em~~ane$

Collect and document data:

0

CSP, synovial, peritoneal

e
a

Small (drops) mag. not need PEP

Large (splash) warrants PEP

DateiTime of exposure
Procedure performed during exposure
Nature of exposure (blood, body fluid)
Information about the source
~ o t e n ~ i ainfectious?
ll~

e More severe if deep, and large-bore

needles, visible blood on device
o Less severe if superficial

Fig. 1 General schematic of the considerations and procedures following an occupational exposure. This algorithm serves only as a
suggested approach; although it reflects the PHS guidelines, it is not meant to replace published guidelines. In addition, this algorithm
does not apply to other types of infectious exposures, such as sexual exposures. For specifics, please refer to the text and to the Public
Health Service guidelines."']

894

posure needs to be individualized on a case-by-case basis.

Additionally, this algorithm only pertains to occupational
exposures and not to exposures differing in nature, such as
sexual exposures.
Because evidence suggests that systemic infection does
not occur immediately following primary HIV exposure,
there appears to be a period of time in which initiation of
post-exposure prophylaxis promptly after occupational
exposure may prevent or inhibit systemic infection by limiting viral replication and proliferation. The consensus is
that post-exposure prophylaxis should, therefore, be initiated as soon as possible following exposure, ideally
within a few hours of exposure, because some animal data
show a reduction in post-exposure prophylaxis efficacy
with delayed initiation.[22.231Post-exposure prophylaxis
may be beneficial even up to 36 hour after exposure, but
the efficacy of post-exposure prophylaxis given this late is
largely undetermined. The optimal duration of post-exposure prophylaxis is unknown, but presently, the Public
Health Service guidelines recommend a 4-week regimen
of zidovudine and lamivudine with or without a protease
inhibitor."']
Following an occupational exposure, it is vital that
healthcare workers are cognizant of institutional policies
and procedures to allow for the timely and organized collection of data and initiation of post-exposure prophylaxis
if indicated. Institutions must have policies and procedures
in place to react quickly to occupational exposure to avoid
unnecessary delays in therapy. The date and time, details
pertaining to the type of activity being performed, nature
of the exposure (type, amount, severity, percutaneous,
mucous membrane, time of contact, condition of skin),
and details about the source (HIV infected, viral load,
history of antiretroviral therapy) should be recorded in the
healthcare worker's medical record. It is recommended
that skin sites or wounds that are contaminated should be
washed with soap and water."'] The use of antiseptics
may be considered, but application of caustic substances
such as bleach is not recommended, as this would compromise the integrity of the skin barrier. Mucous membranes should be flushed extensively with water."']
Following each occupational exposure, proper assessment of the risk for HIV transmission should be performed by qualified personnel. If at all possible, the
source patient should be evaluated for HIV, HBV, and
HCV status to help rule out viral infection."'] Information
pertaining to intravenous drug use and other source risk
factors relevant for consideration of post-exposure prophylaxis should be sought. If this information is unavailable, the source person should be notified of the
incident and consent sought to facilitate testing for serologic evidence for viral infection. If the source is sero-

Universal Precautions and Post-exposure Prophylaxis for HIV

negative for virus at the time of exposure, with no clinical

manifestations of HIV infection, then no further testing of
the source is needed."'] Inevitably, there will be occasions where the source is unknown. In these instances, the
Public Health Service recommends assessing the risk for
HIV transmission and the need for post-exposure prophylaxis based on integration of the nature of exposure
and epidemiological information."']

Although there are some data in animals, there is limited

information available that can be used to assess the efficacy of post-exposure prophylaxis in humans. This is a
manifestation of the infrequent rate of seroconversion of
healthcare workers following exposure to HIV-infected
blood and makes it doubtful that a prospective study with
adequate statistical power could be performed. The notion
of using zidovudine as post-exposure prophylaxis was
addressed by the CDC in 1990 and has been shown to be
beneficial by a retrospective case-controlled study, which
documented the risk for HIV infection among healthcare
workers who used zidovudine as post-exposure prophylaxis reduced by 81%.[6,141However, there are at least 14
instances of zidovudine post-exposure prophylaxis failure,
and there is growing concern regarding transmission of
zidovudine-resistant virus, especially if the source patient's HIV treatment regimen included z i d ~ v u d i n e . " ' ~ ~ ~ ~
Despite the fact that zidovudine has been shown to be
effective in reducing perinatal transmission, it cannot be
concluded that it is effective in reducing occupational
exposure HIV transmission, because the occupational exposure route is not similar to the mother-to-infant route of

PTI

TH

Because the treatment of HIV infection is rapidly evolving

and takes into consideration multiple issues such as viral
resistance and optimal drug combination regimens, there is
growing concern over which drug or drugs should be used
as the standard for post-exposure prophylaxis. Presently,
there are no data available to assess whether the addition of
other antiretrovirals to zidovudine enhances the efficacy of
post-exposure prophylaxis regimens, or whether the increased prevalence of zidovudine resistance is an important factor for post-exposure prophylaxis regimen selection
and efficacy. The CDC states that zidovudine should be
considered for all post-exposure prophylaxis regimens,
because it is the only agent that data supports efficacy for

Universal Precautions and Post-exposure Prophylaxis for HIV

post-exposure prophylaxis. Lamivudine should usually

be added for increased antiretroviral activity and activity versus zidovudine-resistant viral strains."] The current Public Health Service guidelines maintain that it is
reasonable to continue zidovudine as the drug of choice
in post-exposure prophylaxis regimens, and there has
been no additional information to suggest altering lamivudine as the second agent for post-exposure prophylaxis."o1 Table 2 lists the commonly used antiretroviral
agents in post-exposure prophylaxis regimens, along
with the usual dose and expected adverse effects. Other
nucleoside reverse transcriptase inhibitors (NRTIs) that
may be used with zidovudine for post-exposure prophylaxis are didanosine and zalcitabine, resulting largely from documented efficacy and use in combination

895

with zidovudine for treatment of HIV.[261The addition

of protease inhibitor drugs such as indinavir, nelfinavir,
and efavirenz are generally reserved for an expanded
post-exposure prophylaxis regimen following high-risk
exposures in lieu of their additional toxicity and drug
interactions. Nonnucleoside reverse transcriptase inhibitors such as delavirdine and nevirapine are generally
not included in post-exposure prophylaxis regimens.
The use of any drug, even as a prophylactic measure,
may be associated with adverse effects. Adverse effects
of antiretroviral medications are well-described in the
HIV population; however, there is sparse data about adverse effects in the non-HIV-infected individuals. Between October of 1996 and December of 1998, an HIV
post-exposure prophylaxis registry prospectively followed

Table 2 Post-exposure prophylaxis regimens

Drug($)"

Indication

Zidovudine

In combination
with lamivudine for
occupational exposures
that have recognized risk
for HIV transmission

Lamivudine

In combination with
zidovudine for
occupational exposures
that have recognized risk
for HIV transmission

Indinavir

Nelfinavir

Drug regimen

Adverse effects

Specifics

Basic regimen:
Zidovudine 300 mg
BID, given with
lamivudine for
28 days
Basic regimen:
Lamivudine 150 mg
BID given with
zidovudine for
28 days

Nausea, vomiting,
headache, fatigue,
anemia, neutropenia

Renal excretion
of metabolite
Food may affect peak
plasma concentrations
but not overall exposure

Occasional nausea,
headache, diarrhea, rash

Renal excretion,
requires dose
reduction based
on creatinine
clearance
Food does not affect
bioavailability

For use with zidovudine

and lamivudine in cases
where there is an increased
risk for HIV transmission
(i.e., source has high viral
titer or large volume
exposure)

Expanded regimen:
Zidovudine 300 mg
BID, lamivudine 150 mg
BID, and indinavir 800 mg
TID for 28 days

Dose-related
hyperbilirubinemia,
nephrolithiasis, metallic
taste, rash, dry mouth/
mucous membranes

Hepatic elimination
Give with water at
least 1 hr prior,
or 2 hr after a meal;
food will substantially
reduce bioavailability
Minimum of 48 oz
fluids daily to reduce
nephrolitbiasis
Numerous drug
interactions

For use with zidovudine

and lamivudine in cases
where there is an increased
risk for HIV transmission
(i.e., source has high viral
titer or large volume
exposure)

Expanded regimen:
Zidovudine 300 mg
BID, lamivudine
150 mg BID,
and nelfinavir
750 mg TID for
28 days

Diarrhea, rash,
asthenia, anemia

Hepatic elimination
Food will increase
bioavailability ;
take with light snack

aConsider potential drug interactions with other concurrent medications.

(From Refs. [lo] and [27].)

596

healthcare workers receibing post-exposure prophylaxis

following occupational exposure and monitored them for
adverse effects.[271Of the 250 healthcare workers who
completed a post-exposure prophylaxis regimen, and for
whom follow-up data was available, 76% reported some
symptoms or adverse events.'271 The most frequently reported symptoms were nausea (57%), fatigue/malaise
(38%), headache (IS%), vomiting (16%), and diarrhea
(14%). Minor laboratory abnormalities were reported in
8% of healthcare workers.[271Of those healthcare workers
who discontinued all post-exposure prophylaxis drugs.
50% cited symptoms or adverse effects as the reason for
disc~ntinuation.[~~]
Little is known regarding the potential effects of antiretroviral drugs on the developing fetus. Although
carcinogencity or mutagenicty is evident in screening
tests for zidovudine and all other FDA-licensed NRTIs,
limited data on zidovudine use in the second or third
trimesters of pregnancy was not associated with serious
adverse effects."' 25' Whether lamivudine is teratogenic
is unknown.['] This complicates the decision to provide
post-exposure prophylaxis to pregnant women: however,
pregnancy should not preclude the use of optimal postexposure prophylaxis, and post-exposure prophylaxis
should not be denied to a healthcare worker solely on
the basis of pregnancy."" In these situations, the patient
shall reserve the right to decline post-exposure prophylaxis after they have been informed about the risk of HIV
transmission given the nature of the exposure, limited
data regarding teratogenicity in various trimesters of pregnancy, and the risks versus benefits of post-exposure prohylaxis therapy.
The impact that an occupational exposure can inflict on
a healthcare worker and their family is enormous. Healthcare workers should receive post-exposure counseling and
education. along with a detailed synopsis of what events
the healthcare worker may expect, including the need for
follow-up HIV antibody testing. Additionally, facts about
the risk for transmission and other issues such as the
choice, efficacy. adverse effects, and adherence of postexposure prophylaxis medications should be discussed.
Additionally, the possible need for sexual abstinence
or use of a condom to prevent secondary transmission to
their partners should be addressed in a manner allowing
for questioning and feedback. Organ dysfunction, concurrent disease states, and other medications the healthcare
worker was previously taking on a regular basis, and the
potential for drug interactions with post-exposure prophylaxis medications must be considered. Exposed healthcare
workers should be reminded to refrain from donation of
blood. plasma. organs, tissue. and semen donation, and
to temporarily discontinue breastfeeding."']

Universal Precautions and Post-exposure Prophylaxis for HIV

Table 3 Available resources and registries for HIV

post-exposure prophylaxis
Resource or registry

Centers for Disease

Control

National Clinicians'
Postexposure Hotline
Food and Drug
Administration
Antiretroviral
Pregnancy Registry
UCSF On-line
information
National HIV/AIDS
Clinician's Consultation
Center
HIVIAIDS Treatment
Information Service (ATIS)

Contact information"

Telephone: (404) 639-6425

(For reporting HIV
seroconversion in HCWs that
received postexposure
prophylaxis)
or www.cdc.gov1hiv
(for general information)
Telephone: (888) 448-4911;
(888) 737-4448;
(888) PEP4HIV
Telephone: (800) 322-1088
(For reporting unusual or
severe toxicity from PEP
regimens)
Telephone: (800) 258-4263
http:llarvdb.ucsf.edu
(For information about
antiretroviral drugs)
http:llwww.ucsf.edu/hivcntr

http:/lwww.hivatis.org
Telephone: (800) 448-0440

"Contact information is subject to change.

There are numerous factors to consider before and after

initiation of a post-exposure prophylaxis regimen, which
may lead to providers and educators feeling overwhelmed
and unsure about some choices that need to be made. To
facilitate this process, Table 3 lists some available resources and registries that one may contact to aid in the
decision process.

The practice of universal precautions is Federal Law in

the United States, and it is the responsibility of every
employer or institution that healthcare workers have the
resources and training necessary to adhere to these safety
precautions.[21 Additionally, support for continued practice of universal precautions needs to come from all levels
of administration. Observations by Gershon et al. indicate
that one of the strongest correlates with compliance is the
institutional "safety climate.' '[''I This implies that if
healthcare workers perceive their work environment to be
conducive to practicing universal precautions, then they
will be more likely to do so.

897

Universal Precautions and Post-exposure Prophylaxis for HIV

Each occupational exposure needs to be considered on

a case-by-case basis. The risk of occupational HIV transmission appears to be greatest if the exposure is percutaneous in nature. In order to optimize post-exposure
prophylaxis, the duration between exposure and initiation
of therapy must be kept at a minimum: preferably within a
few hours. Despite the concern of viral resistance, postexposure prophylaxis regimens should include 4 weeks of
zidovudine plus lamivudine, and under certain circumstances, a protease inhibitor.
Although the focus of this discussion emphasizes HIV
infection, healthcare workers must be aware that other
blood-borne pathogens such as HBV and HCV may also
be of significant concern. The healthcare worker is encouraged to refer to alternative references for more detailed discussions pertaining to these infection^.[^*'^^'
Unfortunately, healthcare worker exposure to infectious blood and body fluids will continue to be a reality.
Hopefully, with the practice of basic infection control in
conjunction with universal precautions, this can be kept
at a minimum. Universal precautions will likely be an
evolving process considering the increased prevalence of
viral resistance, and the continued emergence of new,
and more difficult to treat infectious entities.

RE
1. Centers for Disease Control. Recommendations for prevention of HIV transmission in healthcare settings. Morb.
Mort. Wkly. Rep. 1987, 36 (Suppl. 2S), 1s- 18s.
2. Occupational Safety and Health Administration. Occupational exposure to bloodborne pathogen: Final rule. Fed.
Regist. 1991, 56, 64004-640182.
3. DeJoy, D.M.; Gershon, R.R.M.; Murphy, L.R.; Wilson,
M.G. A work-systems analysis of compliance with universal precautions among health care workers. Health Educ.
Q. 1996, 23 (2), 159-174.
4. Center for Disease Control. Update: Universal precautions
for prevention of transmission of HIV, HBV, and other
blood-borne pathogens in health care workers. Morb. Mort.
Wkly. Rep. 1988, 37, 229-234.
5. Centers for Disease Control. Guidelines of prevention of
transmission of human immunodeficiency virus and hepatitis B virus to healthcare and public-safety workers. A
Response to P.L. 100-607. The Health Omnibus Programs
Extension Act of 1988. Morb. Mort. Wkly. Rep. 1989, 38
(S-6), 3-37.
6. Centers for Disease Control. Public Health Service statement on management of occupational exposure to human
immunodeficiency virus, including considerations regarding zidovudine post-exposure use. Morb. Mort. Wkly. Rep.
1990, 39 (RR-l), 1-14.

7. Centers for Disease Control. Recommendations for preventing transmission of human immunodeficiency virus
and hepatitis B virus to patients during exposure-prone
invasive procedure. Morb. Mort. Wkly. Rep. 1991, 40
(RR08), 1-9.
8. Center for Disease Control. Provisional public health service recommendations for chemoprophylaxis after occupational exposurre to HIV. Morb. Mort. Wkly. Rep. 1996,
45 (22), 468-472.
9. Centers for Disease Control. Guideline for infection control in health care personnel, 1998. Am. J. Infect. Control
1998, 26, 289-354.
10. Centers for Disease Control. Public health service guidelines for the management of healthcare worker exposures
to HIV and recommendations for post-exposure prophylaxis. Morb. Mort. Wkly. Rep. 1998, 47 (RR-7), 128.
11. Hopkins, C.C. Implementation of universal blood and body
fluid precautions. Infect. Dis. Clin. North Am. 1989, 3 (4),
747 762.
12. Ippolito, 6.; Puro, V.;De Carli, G. The Italian study
group on occupational risk of HIV infection. The risk of
occupational human immunodeficiency virus infection in
health care workers. Arch. Intern. Med. 1993. 153, 14511458.
13. Fahey, B.J.; Koziol, D.E.; Banks, S.M.; Henderson, D.K.
Frequency of nonparenteral occupational exposures to
blood and body fluids before and after universal precautions training. Am. J. Med. 1991, 90, 145-153.
14. Cardo, D.M.; Culver, D.H.; Ciesielski, C.A., et al. A casecontrol study of HIV seroconversion in health care workers
after percutaneous exposure. N. Engl. J. Med. 1997. 337,
1485-1490.
15. Gershon, R.R.M.; Karkashian, C.; Felknor, S. Universal
precautions: An update. Heart Lung 1994. 23 (4), 352358.
16. Mangione, C.M.; Cerberding, J.L.; Cummings, S.R. Occupational exposure to HIV: Frequency and rates of
underreporting of percutaneous and mucocutaneous exposures by medical house staff. Am. J. Med. 1991, 90,
85-90.
17. Hamory, B. Underreporting of needlestick injuries in a
university hospital. Am. J. Infect. Control 1983, I 1 (3),
174- 177, Centers for Disease Control and Prevention.
HIV/AIDS Surveill. Rep. 1993, 5 (no.3), 13.
18. Centers for Disease Control Cooperative Needlestick
Surveillance Group. Surveillance of health care workers
exposed to blood from patients infected with human immunodeficiency virus. N. Engl. J. Med. 1988. 319, 11 181123.
19. Centers for Disease Control and Prevention. HIV/AIDS
Surveill. Rep. 1993, 5 (3), 13.
20. Wollowine, J.; Mast, S.; Gerberding, J. Factors Influencing Needlestick Infectivity and Decontamination
Efficacy: An ex vivo Model. In 32nd Interscience Conference on Antimicrobial Agents and Chemotherapy,
-

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898
Aizalzeirn, CA, American Society for Microbiology, 1992,
Abstract 11 88.

21.

Mast, S.; Gerberding, J. Factors predicting infectivity following needlestick exposure to HIV: An in vitro model.
Clin. Rcs. 1991; 39, 58A.
22. Martin, L.N.; Murphy-Corb, M.; Soike, K.F.; DavisonFairbum, B.; Baskin, G.B. Effects of initiation of 3-azido,
3deoxythmidine (zidovudine) treatment at different times
after infetion of rhesus monkeys with simian immunodeficiency virus. J. Infect. Dis. 1993, 168, 825-835.
23. Shih, C.-C.; Kaneshima; H.; Rabin, L., et al. Post-exposure
prophylaxis with zidovudine suppresses human immunodeficiency virus type 1 infection in SCID-hu mice in a
time-dependent manner. J. Infect. Dis. 1991,163,625- 627.
24. Tokars, J.1.; Marcus, R.; Culver, D.H., et al. Surveillance
of HIV infection and zidovudine use among health care
workers after occupational exposure to HIV-infected
blood. Arch. Intern. Med. 1993, 118, 913-919.

Connor, E.M.; Sperling, R.S.; Gelber, R., et al. Reduction

of maternal-infant transmission of human immunodeficiency virus type 1 with zidovudine treatment. N. Engl. J.
Med. 1994, 331, 1173-1180.
26. Center for Disease Control. Guidelines for the use of
antiretroviral agents in HIV-infected adults and adolescents. Morb. Mort. Wkly. Rep. 1997, 175, 1051-1055.
27. http://www.cdc.gov/ncido/hip/3lood/PEPRegistry.pdf
(accessed Dec. 2000).
28. Center for Disease Control. Immunization of healthcare
workers. Recommendations of the Advisory Committee on
Immunization Practices (ACIP) and the Hospital Infection
Control Practices Advising Committee (HICPAC). Morb.
Mort. Wkly. Rep. 1997, 46, RR-18.
29. Centers for Disease Control. Recommendation for prevention and control of hepatitis C virus (HCV) infection and
HCV-related chronic diseasc. Morb. Mort. Wkly. Rep.
1998, 4 7 (RRlg), 1--39.

25.

DISTINGUISHED PERSONALITIES

Charles Walton has contributed substantially to the

development and maturation of clinical pharmacy.
Among his most important contributions were the development of drug information, the introduction of rational therapeutics into the pharmacy curriculum. and his
strong advocacy for a sustained clinical practicum as
an essential component i n the training of competent clinical pharmacists. c: is regarded by many in the discipline as the father or drug information training and one
of the founding fathers of the American College of Clinical Pharmacy.

Charles Anthony Walton was born on April 3, 1926, in

Auburn, Alabama, but was raised in Tallassee, which is
35 miles northeast of Montgomery. He recalls how
people passing through his hometown accused the city
fathers of leaving out the ha in spelling the name of
their town. Tallasseeans, according to Walton, are a noble
people and would tell such critics that they needed to
travel further south into the panhandle of Florida if it was
laughter they wanted.
Waltons interest in pharmacy began when he was a
young lad and an avid listener of radio. Television had
899

900

not yet been invented. Walton was particularly interested

in radio commercials and some of their dramatic claims.
He remembers one mellifluous radio announcer saying
Take Sal Hapitica for the smile of health and brush
with Ipana for the smile of beauty. But what really
piqued his interest in drugs was the radio commercial
that advertised Carters Little Liver Pills. He found it incredible that such a small, round pill could produce such
extraordinary and wonderful outcomes. In fact, he was
so intrigued with commercials that he decided that when
he grew up he would pursue either a career in radio announcing or in the study of drugs. His Southern drawl,
however, pretty much excluded a career in radio.
After graduating from Tallassee High School, Walton
enlisted in the United States Navy and served two years
during the Second World War. After completing his
tour of duty in the Navy, he enrolled as a freshman at
Auburn University, where he would later study pharmacy.
He was a good student of pharmacy and his interest and
curiosity in pharmacology continued to grow. However,
the faculty did not readily encourage his enthusiasm and
desire to do postgraduate work in pharmacology and
suggested instead that he enter pharmacy practice where
he could earn a decent living. But there was one faculty
member who learned of Waltons desire to continue his
education and pursue a graduate degree in pharmacology.
She had a masters degree in hospital pharmacy from
Purdue University, and she alone urged Walton to follow
his dreams and enter graduate school. He did just that.
After one year at Purdue, Walton was awarded a master of
science degree in pharmacology, and in 1950 he accepted
a faculty position at the University of Kentucky School of
Pharmacy in Louisville.
Later on Walton took advantage of a part-time sabbatical to begin work on a Ph.D. degree in pharmacology
at Purdue. He completed the program in 1956. Shortly
after that, the University of Kentucky School of Pharmacy
moved to Lexington, and, in 1960, opened a medical
school on this new Lexington campus. The presence of a
medical school on the same campus as the pharmacy
school led Walton to dream about training pharmacy and
medical students in the same educational environment. He
presented his idea to the two deans. The dean of the
medical school supported the idea, but the dean of the
pharmacy school had some reservations, and so Waltons
dream was temporarily suspended.
Walton may have been dismayed but he was not
distracted. He soon became acquainted with the Director
of Hospital Pharmacy at the University of Kentucky
Medical Center-a very bright and energetic young man
who had some novel ideas of his own. Charles Walton and
Paul Parker rapidly developed a strong collegial relation-

Walton, Charles

ship. They were so enthusiastic and passionate about their

ideas that often they would work well into the early
morning hours generating new concepts and crafting plans
to expand the mission of pharmacy. These late-night
meetings were charged with so much creative energy that,
the next days, neither man felt tired, but instead longed to
get back together to continue their stimulating discussions. Walton recalls one occasion when Parker invited
him to his Lexington home to explore the idea of training
pharmacists to provide rational drug information to hospital formulary committees and to physicians taking care
of patients in the hospital. They worked tirelessly during
the night, drafting a concept paper that outlined the establishment of a hospital pharmacy service that would be
dedicated to the advancement of rational therapeutics.
They called the new service initiative drug information.
They knew that their idea would be popular with the
medical schools chairman of medicine, Ed Pellegrino,
because Pellegrino was a pioneer and national leader in
the teaching and practice of rational drug therapy. A key
development in the concept came about with the hiring of
David Burkholder as the first director of the drug information center. Working together, Burkholder and Pellegrino developed the first hospital formulary that was
based entirely on the principles of rational therapeutics.
(Today, we refer to rational therapeutics as evidencedbased medicine.) The major underlying principle is that
no drug should be used in the hospital setting that has not
been proven in proper studies to be safe and more effective than alternative therapies.
The idea of melding drug information with pharmacists
monitoring drug therapy at the patients bedside came
from a drug information conference held in the early
1960s at the Carnahan House, located on a horse farm
near Lexington. The conference was sponsored by the
American Society of Hospital Pharmacists (ASHP). At
that conference, William Smith presented the so-called
9th floor project being conducted at the University of
California at an Francisco. The marriage of drug information to hospital pharmacists working at the bedside
gave birth to a new concept in pharmacy that the conference delegates referred to as clinical pharmacy. Those
representing ASHP at the conference expressed some
concern that a new competing organization might emerge.
The conference attendees toyed with the idea of establishing an association of clinical therapologists. A delegate
from Canada quickly moved that the organization be
named the International Association of Clinical Therapologists (IACT ). It was all in jest.
Walton became the director of the hospital pharmacys
Drug Information Center in 1967. He also started working
more closely with the hospital pharmacy residency pro-

Walton, Charles

gram directed by Paul Parker. He continued his tcaching

of pharmacology in the pharmacy school but with a
different slant, incorporating in his lectures the principles
of rational therapeutics. At that time, James Doluisio, who
had recently joined the pharmacy school faculty at the
University of Kentucky, was serving as chairman of the
curriculum committee. Doluisio had been a key player in
thc development of the Pharm.D. Program at the
Philadelphia Collegc of Pharmacy and Science. Walton
was asked to chair a committee to develop a doctor of
pharmacy program at Kentucky. Working closely with
Doluisio and Parkcr, Waltons committee successfully
established a strong post-baccalaureate Pharm.D. program
dccply rooted in rational therapeutics and including a
sustained clinical practicum through the hospital pharmacy residency program. Waltons dream of pharmacy
students being educated and trained alongside medical
students had finally become a rcality.
In 1973, Doluisio became Dean at the University of
Tcxas College of Pharmacy in Austin. One of his first
administrative dccisions was to hirc Walton to develop a
Pharm.D. program in Texas. Because there was no medical school in Austin, Doluisio negotiated an agrcement
with the University of Texas Health Science Center in San
Antonio to establish a jointly administered post-baccalaureate Pharm.D. degree program. And, because there
was no existing hospital pharmacy residency program at
the hcalth science center in San Antonio, a one-year sustained clinical practicum was incorporated as part of the
academic program. Walton was appointed associate dean
for clinical programs and recruited a young, dedicated

901

faculty to help build the Pharm.11. program at Texas. The

new program contained a strong didactic background in
the biomedical sciences and provided expericntial training
in medicine, pediatrics, psychiatry, ambulatory care, and
drug information.
Walton strongly insisted that pharmacists engaged in
therapeutic decision making and pharmacothcrapy consultations had to bc well-traincd clinicians who were
directly involvcd in the management of patients. The
founders of thc American College of Clinical Pharmacy
(ACCP) were strongly influenced by Waltons philosophy
on what constitutes a credible clinical pharmacy practitioner as they dcvcloped the mission, goals, and purpose
of the organization. In fact, Walton played a prominent
role in the early development of the College not only as
a source of encouragement, wisdom, and guidance but
also by serving ACCP as an advocate before the pharmacy academy, particularly the American Association of
Colleges of Pharmacy. The major impetus of ACCP was
to strive for excellence. The new organization was criticized by some as being composed of elitists. When
questioned about this, Walton said, If striving for excellence makes me an elitist, then I am an elitist. Because of his important contributions to the development
of the ACCP, Walton was inducted as the first honorary
fcllow of the College.
Charles Walton will forever be admired for his
intellect, his humor, his wisdom, and his passion for
excellence. To thc pioneers in clinical pharmacy and to
many of those who followed in their footstcps, Charles
Anthony Walton is a hero and bcloved friend.

DISTINGUISHED PERSONALITIES

University of Minnesota, Minneapolis, Minnesota, U.S.A.

I
Lawrence C. Weaver is one of the true patriarchs of clinical pharmacy. He was Dean of The College of Pharmacy
at the University of Minnesota from 1966-1984 and
1994- 1995. He initiated the post-B.S. Pharm.D. program
in 1971. His international efforts have resulted in the
establishment of clinical pharmacy educational programs
in Europe, Africa, the Middle East. and the Pan-Pacific
Rim. He led efforts to facilitate the worldwide access and
distribution of orphan drugs required to treat patients with
rare diseases while working for the Pharmaceutical Manufacturers Association from 1984-1989. In 1997, the
University of Minnesota recognized his life-long contributions and leadership by naming the Pharmacy and Nursing building, Weaver-Densford Hall, in his honor.

Born January 23. 1924 in Bloomfield, Iowa to Wilbur and

Faye Weaver, Lawrence C. Weaver was the eldest of
three sons. He spent his childhood living and learning on
the family farm and one-room school in southeastern
Iowa. He joined the U.S. Air Force in 1942, served as a
pilot, and rose to the rank of Captain. He flew in the
China-Burma-India theatre and earned the Distinguished Flying Cross and an Air Medal. He returned to
the States and earned a Bachelor's degree in Pharmacy
from Drake University in 1949.
Larry married Delores (Dee) Hillman on September
9, 1949 in Oakland. California. Dee and Larry adopted
and raised four children. Their extended family includes
the thousands of pharmacy students throughout the
world who have benefited from their personal support
and guidance.

After earning his Ph.D. in pharmacology from the

University of Utah in 1953, Weaver joined the Pitman902

Moore Company. He was the Head of Biomedical Research that included both human and veterinary research
in pharmacology, microbiology, and parisitology. In
1964 while with Pitman-Moore (now a division of the
Dow Chemical Company), Weaver organized and directed the Biohazards Department where he pioneered
efforts in the emerging field of biological hazard (environmental) control.
Weaver's research interests in Pharmacy Education,
Healthcare Delivery Systems, and Drug Combinations in
Therapy. among others, led him to become the fourth Dean
of the College of Pharmacy at the University of Minnesota
in 1966. As the Dean of Pharmacy and Professor of Pharmacology in the School of Medicine, Weaver was farsighted enough to bring the pharmacy program at the
University of Minnesota into the newly organized Health
Sciences Center in order to foster interdisciplinary education and the clinical role of pharmacists. He introduced the two-year post-Baccalaureate program that became the basis for the Pharm.D. program. His vision of
clinical pharmacy faculty and PharmD. students practicing and learning side-by-side with physician faculty and
medical students became the platform for the future
expansion and growth of the Pharm.D. program. His 10year effort to join the Medical, Dental, Nursing, and
Public Health programs on the campus of the University
Hospital culminated with approval of funding for the
Health Sciences Unit F building. which was built in
1981. He lead the effort to secure the over $20,000,000
required to build the nine-story building that houses the
College of Pharmacy and the School of Nursing. The
building was dedicated in 1996 when it was renamed
Weaver-Densford Hall to honor Lawrence C. Weaver
and Katherine Densford, the first Dean of the School of
Nursing at the University of Minnesota.
Dean Weaver initiated the two-year post-Baccalaureate
Pharm.D. program at the University of Minnesota in
1971. As the Dean of one of the first clinical pharmacy
programs in the United States, Weaver collaborated with
the Medical School to have his Pharm.D. students take
pathophysiology classes with the medical students in
order to both bring essential disease-related content to the
Encyclopedia of Clinical Pharmacy
DOI: 10.1081E-ECP 120006258
Copyright 0 2003 by Marcel Dekker, Inc. All rights reserved.

~ e a v c Lawrence
~,

pharmacy curriculum and to introduce medical students

and faculty to clinical pharniacists.
relentless in his belief that clinically prepared pharmacists
could substantially improve the quality of hcalth care.
Under his leadership, in 1981 the Pharm.D. curriculum
expanded from a two-year post B.S. program to a six-year
Pharm.D. degree. Weaver fclt that the curriculum should
be designed to increase the clinical skills of all cntrylevel pharmacists. The new curriculum featured courses
in pharmacokinctics and biopharmaceutics, as well as a
pathophysiology and therapeutics course sequence taught
for the first time entirely by clinical pharmacy faculty.
Larry, as he is known by the thousands of students he
taught and mentored, brought a vision of improvcd patient care through clinical pharmacy service that inspired
students and clinical faculty for over three decades.
After 18 years as the Pharmacy Dcan, Weaver left
academia to become the Vice President of Professional
Relations for the Pharmaceutical Manufacturers Association (PMA). In his role as the Executive Director of
the PMA Commission for Rarc Diseases, he championed
the goal of making orphan drugs available to patients
throughout the world who suffer from rare diseases. His
efforts have resulted in over 800 drugs, serums, and vaccines being designated as orphans by thc Food and
Drug Administration. His continued efforts to help those
in need of orphan drugs required interaction with federal
agencies, pharmaceutical firms, researchers, practitioncrs,
and patients and their families. He has been described as a
peacemaker and a matchmaker who can bring industry,
academia, and families together.

Larry Weaver is recogniad around the world for his

leaderrhip and advocacy for clinical pharmacy. He as-

903

sisted international pharmacy leaders from scveral

countries in the design and implementation of clinical
pharmacy programs. Throughout the late 1970s and
1980s, Weaver served as an educational consultant
and advisor to numerous countries including
University, Royal Danish Collcgc of Pharmacy, Wclsh
School of Pharmacy, Universities in Cairo, Tanta, Nairobi, Zimbabwe, Republic of South Africa, Amman Jordan, and the University of Sains Malaysia. In his role as
Education Advisor to the University of Riyadh, Saudi
Arabia, Weaver assisted in the conversion of the curriculum from the Europcan System to the credit system
and to the use of English as the language for teaching in
pharmacy. He worked with Saudi faculty to cstablish clinical pharmacy courses and initiated the first continuing
cducation program in pharmacy.
Larry Weaver is one of pharmacys most well respected leaders due to his endless efforts to establish
clinical pharmacy as the standard for American pharmacy
education. He served in leadcrship roles including President and Vice President of both the Academy of Pharmaceutical Sciences of the APhA and the American
Association of Colleges of Pharmacy. Hc also served as a
member of first Board of Trustees of the Research
Institute for the American College of Clinical Pharmacy.

In 1994, Weaver was summoned back to the Deanship of

the College of Pharmacy at the University of
He served in this capacity for two years and directed the
implementation of the new entry level Phar1n.D. curriculum. Since 1996, Dean Emeritus Lawrence C. Weaver
has been a mcmbcr of the Peters Institute of Pharmaceutical Care, developing educational and rescarch programs
in pharmaceutical care practice. Larry Weaver has had a
distinguished career in pharmacy.

PROFESSIONAL ORGANIZATIONS

ti
Patrice Trouiiler
University Hospital of Grenoble, Grenoble, France

MISSIONS
The World Health Organization (WHO) is a United Nations specialized agency, which has 193 member countries. Its objective is the attainment by all people of the
highest possible level of health. WHO has four main
constitutional functions: to act as the directing and cooperating authority on international health issues; to provide assistance including maintaining epidemiological
and statistic services; to promote research; and to develop
and promote international norms or standards. The work
of WHO is carried out by the World Health Assembly, the
Executive Board, the Secretariat, and six regional offices.

The origin of WHO dates from the need for international

preventive and control measures against epidemics such
as cholera and plague, particularly in the European region,
during the nineteenth century. Later, different cooperation
arrangements were adopted and the International Agency
for Public Hygiene was established in Paris (1907) to
control epidemics and communicable diseases. Later the
Health Organization of the League of Nations was set up
in Geneva (1919). During the San Francisco Conference,
which laid the foundations for the United Nations Organization (1945), it was decided to establish a permanent
and autonomous international organization for health issues. In June 1946, an international health conference
convened in New York by the UN Secretariat approved
the creation of WHO. Its specific Constitution, following
a ratification by 61 states, was set into place on April 7,
1948 (now marked as World Health Day). WHO, once the
main player, is now one of many UN and other organizations or institutions concerned with health. The World
Bank plays an increased financial and technical role, bilateral agencies and the private sector as well, such as the
non governmental organizations, make significant contributions to international health.

904

With 193 member states currently, WHO has a constitutional mandate to direct and coordinate international efforts in relation to health, to promote technical cooperation among nations, to develop and transfer appropriate
health technology, and to set global standards for health.
Finally its overall mission is the attainment by all people
of the highest possible level of health, with special emphasis on closing the gaps within and among countries.
According to WHO, health is defined as a state of complete physical, mental, and social well-being and not
merely the absence of disease or infirmity. This ambitious and idealistic objective was summarized by the
slogan -Health for All by the Year 2000.] In spite of
major achievements (e.g., smallpox eradication declared
in 1980; polio and guinea-worm disease on the threshold
of eradication; leprosy, lymphatic filariasis and neonatal
tetanus targeted for elimination), this health for all
objective is currently challenged by the spread of the
HIV/AIDS pandemic; by the persistence of malaria and
many other parasitic diseases; by tuberculosis, which is
still a major health priority since 1948; and increasing gap
between least developing and developed countries (e.g.,
average life expectancy is 38.5 in Zambia and 79.5 in
Sweden; 2 million children die each year from diseases
for which vaccines exist; etc.), and the growing impact of
globalization on health issues.r21
To carry out its missions, WHO is endowed with a
decentralized system including a central office (the Geneva headquarters) and six regional offices. At the central
level, the World Health Assembly (WHA). a deliberating
body which represents the 193 member states, sets the
policy, approves the budget, and passes agreements or
conventions (to be adapted by the member states). In addition, it can issue international health regulations for
technical matters (WHO normative functions) directly
and compulsorily applicable to member states. The WHA
elects the Executive Board composed of 32 members and
appoints a Director-General (DG) to give effect to the
decisions and policies of the Health Assembly and to

Encyclopedia of Clinical Pharmacy

DOI: 10.1081/E-ECP 120006305
Copyright C 2003 by Marcel Dekker. Inc. All rights reserved.

905

advise it. At the decentralized level, six regional offices

have been created by the
A to take local specificities
into account.
The funding for WHO comes from member countries
and dues are based on their national economies and as
well on extra-budgetary funds allocated by countries or
institutions earmarked for specific purposes or projects.
The total budget for W 0 was about $1.3 billion in 2000,
and this amount has not increased in recent years despite
increased demands on the organization. One problem has
been the persistent failure of some major funders to fully
pay their assessed dues and the fluctuation in member
states voluntary contributions.

ar

According to articles 2 and 21 of its Constitution, WHO

has a regulatory power for developing, establishing, and
promoting standards and nomenclature (International
Health Regulations). These regulations are limited to
technical matters: health and international quarantine regulations; health codification for international travels: international nomenclature of diseases; nomenclature and
standards with respect to the safety, quality, and efficacy
for pharmaceutical, biological, and similar substances,
including their advertising and labeling: international
standards for biological; international cooperation for
health statistics; food standards (through the joint WHO/
F A 0 Codex Alimentarius Commission); and dependence and misuse of drugs regulations.
Numerous matters related to public health and biomedical sciences can be the subject of Recommendations
but without compulsory nature contrary to international
regulations. WHO Recommendations may be endorsed by
the WHA under article 23 or by the Executive
issued as resolutions (e.g., WHA 52.19 Resolu
revised drug strategy, 1999).
They may be issued by an individual WHO Expert
Committee and included in their reports (e.g., WHO Expert Committee on specifications for pharmaceutical preparations,
cal report number 863, 1996). or issued
as special
publications under the authority of the
DG (e.g., Globalization and access to drugs, health economics and drugs, 1998). Most of the WHO Recommendations are directed at developing countries (e.g.. the
International Pharmacopoeia).
In practice, WHO standards, guidelines, and recommendations serve as advice to member states. They can
however, be adopted as legally binding national regula-

tions if a national authority so desires, or they may form

the basis of national standards and technical regulations.

clivi
In support of its objectives, WHO develops a wide range
of operational activities to provide appropriate technical
assistance, to stimulate and advance work on prevention
and control of epidemic, endemic, and other diseases, and
to cooperate with governments for strengthening health
services. WHO works closely with other UN organizations or programs [e.g., Food and Agricultural Organization (FAO), United Nations Childrens Fund (UNICEF),
United Nations Development Program (UNDP), and the
World Bank], and maintains working relationships with
bilateral agencies and intergovernmental and nongovernmental organizations (NGOs). In addition, nearly 1200
health-related institutions are officially designated as
WHO collaborating centers. More than 50 affect the pharmaceutical sector, such as the Uppsala Monitoring Center
for pharmacovigilance issues.
Communicable diseases
Approximately, 56 million people died in 1999, of which
14 million died from infectious and parasitic diseases with
more than 90% occurring in developing countries. (In rank
order: acute lower respiratory infections, HIVIAIDS, diarrhea, tuberculosis. malaria, measles.) To prevent and
control them, WHO developed and launched activities and
programs in the field such as the Expanded Programme on
Immunization (EPI) in collaboration with UNICEF (EPI
targets are poliomyelitis, measles, diphtheria, whooping
cough. tetanus and tuberculosis); the Onchocerciasis Control Programme; the global programs on AIDS; the Roll
Back Malaria program; the Africa 2000 Initiative on
water supply and sanitation issues; and others.
Noncommunicable diseases
Chronic diseases such as cardiovascular diseases, cancers,
and respiratory diseases, affect both developed and developing countries. WHOS priorities are an integrated and
coordinated approach to prevent, treat, and cure through
disease-specific interventions, global campaigns to encourage healthy lifestyles (e.g., worldwide no-tobacco
day), and healthy public policies promotion.
Emergency and humanitarian action
The emergency and humanitarian division of WHO/HQ
plays an active role in assisting the member states in

906

tackling health emergencies. It relies on its emergency

preparedness and response programs, providing countries
timely support to tackle acute emergency and supporting
them during the reconstruction phase. WHO can assure

coordination with donors (through consolidated appeals),

UN agencies (e.g., UNHCR, UNICEF, WFP) and other

entities involved (e.g., ICRC, NGOs). To face large
movements or sudden influxes of refugees which create

Table 1 WHO Core functions in pharmaceuticals

Core ~ ~ ~ c t i Q n s
National drug policy

Access to essential
drugs

bjectives
0

Help countries formulate

and imolement a national
drug policy (NDP) and
integrate the work into
their national health system
in ensuring commitment of
all stakeholders.
Ensure equitable
availability and affordability
of essential drugs.

CQrn~on~~ts
0

Quality and safety

of drugs

Ensure the quality and

safety and efficacy of
all medicines.
Put into practice
regulatory and quality
assurance (QA) srandards.

Rational use of drugs

Ensure therapeutically
sound and cost-effective
use of drugs by health
professionals (prescribers,
nusses, and dispensers)
and consumers.

(From Ref. [S].)

Implementation and monitoring

of NDP.
Health system development
supported by essential drugs
policies and programs.

Access strategy and monitoring

for essential drugs (in particular
for priority health policies and
newly developed drugs).
Financing mechanisms and
affordable essential drugs.
National and local public
sector drug supply systems
and supply capacity.
Norms, standards, and
guidelines for pharmaceuticals
Drug regulation and QA systems.
Information support for
pharmaceutical regulation.
Guidance for control and use
of psychotropics and narcotics.

Rational drug use strategy

and monitoring through
national strategies.
National standard treatment
guidelines, EDLs, educational
programs.
Independent and unbiased
drug information system.

TQOk

for
developing a NDP.
Indicators for monitoring
NDP, 1999.
Essential Drug List (EDL),
1lthlist, Nov 1999.
Standard indicators to
measure equitable access.
Drug price information.
Operational principles
for good pharmaceutical
procurement, 1999.
Good drug donation
practices, 1999.
The new emergency
health kit, 1998.
Norms, standards and
guidelines developed
and updated.
Quality control
specifications.
Drug nomenclature and
classification.
WHO certification
scheme on the quality
of pharmaceuticals.
Good manufacturing
practices (GMP).
Good laboratory practices
(GLP).
Good clinical practices
(GCP), 1995.
The International
Pharmacopoeia, 1994.
Guide to good
prescribing, 1994.
Medical products and
the internet: a guide
to finding reliable
infomation, 1999.
The use of essential
drugs. gth report of the
WHO expert committee.

World Health Organization

immediate needs for basic health services (e.g., Rwanda

in 1994 and Kosovo in 1999), WHO has collaborated with
most international agencies and NGOs to developed a
standard kit of essential medicines, medical supplies, and
basic equipment called the New Emergency Health
Kit. The same interagency group has developed guidelines for obtaining the maximum benefit from drug
donations through the Guidelines for Drug Donations
de~elopment.[~

Research activities range from epidemiological surveillance for new and re-emerging diseases, the tropical disease research program (WHO/TDR in Geneva, Switzerland) tackling epidemiological research, medicines
research and development (on malaria, trypanosomiasis,
leishmaniasis, Chagas disease, etc.), cancer research
(e.g., International Centre for Cancer Research in Lyon,
France), and monitoring of the progress of genetic engineering laboratories.

HO-Specific Activities in the

Pharmaceutical Sector
While medicines alone are not sufficient to provide adequate healthcare, their health impact is remarkable. The
economic incidence of medicines is substantial, representing less than 20% of total public health expenditure in
developed countries ($138 per capita), but 25-66% in
developing countries ($8-12 per capita). It is clear that
priorities need to be set in order to maximize the health
benefits from limited public pend ding.'^] The rational use
of medicines, their accessibility and quality and the development of national drug policies are therefore critical
and constitute the four main areas of work for WHO.[51
This is the mission of the Department of Essential Drugs
and Medicines Policy created within the Health Technology and Pharmaceuticals cluster (EDM/HTP, Geneva
Headquarters), in close collaboration with the six regional
offices and other stakeholders (Table 1).
Despite the obvious medical and economic importance
of pharmaceuticals, there are still widespread and
persistent problems:

1. Lack of access: Over one-third of the world

population still has no regular access to essential
medicines.
2. Poor quality of medicines: Between 10 and 20% of
sampled medicines fail quality control tests in
developing countries.

9Q7

3. Irrational prescribing and use: Up to 75% of

antibiotics are prescribed inappropriately.
4. Lack of pharmaceutical research and development
for tropical
Reasons are complex and go beyond simple financial
constraints. (In most developed countries, virtually 100%
of the population has health insurance; median coverage
is 35% in Latin America and less than 10% in Africa and
Asia.) Changes in the patterns of disease (e.g., rise of
HIV/AIDS, increasing drug resistance for malaria and
tuberculosis, increase in chronic diseases and diseases of
the elderly) and drug demand also represent major
challenges and contribute to increased spending on drugs
and growing pressure on health resources. The potential
impact of international trade agreements, such as the
World Trade Organization Agreement on trade-related
aspects of intellectual property rights (WTO/TRIPS), is
also a matter of growing concern with relation to access to
new essential medicines (e.g., antiretroviral drugs, antibiotics, second-generation vaccines).[s1 It highlights the
need for strengthened international cooperation and a
stronger public health response.

1. WHO. About WHO. URL: http://www.who.intlaboutwho/

en/healthforall.htm (accessed on Oct. 2000).
2. WHO. The World Health Report 2000. In Health System:
Improving Perjformance; World Health Organization:
Geneva, 2000; 215 pp.
3. WHO. Guidelines for Drug Donations, Revised 1999. In
Interagency Guidelines; World Health Organization:
Geneva, 1999, (WHOEDMPAW99.4).
4. WHODAP. Global Comparative Pharmaceutical Expenditures. In Health Economics and Drugs; WHOIDAP
Series, World Health Organization: Geneva, 1997; Vol.
346.
5 . WHO. WHO and medicines: Role and mission of EDM,
URL: http://www.who.int/medicines/edm-about.html
(accessed on Oct. 2000).
6. WHO. WHO Medicines Strategy. In Framework for Action
in Essential Drugs and Medicines Policy, 2000-2003;
World Health Organization: Geneva, 2000; 70 pp.
7. Trouiller, et al. Drug development for neglected diseases:
A deficient market and a public-health policy failure.
Lancet 2002, 359, 2188-2194.
8. WHO. Globalization and Access to Drugs, Perspectives on
the WTOflRIPS Agreement; WHODAP Series, World
Health Organization: Geneva, 1999; Vol. 7.

PHARMACY PRACTICE ISSUES

atrice Trouillev
University Hospital of Grenoble, Grenoble, France

I
Health is a fundamental human right. Access to healthcare. which includes access to essential medicines, is a
prerequisite for realizing that right. First introduced in
1975, the concept of essential drugs (called essential
medicines since 2001) is now widely accepted as a
pragmatic approach to providing the best of evidencebased and cost-effective healthcare. This is a global concept that can be applied in any country, in private and
public sectors, and at different levels of the healthcare
system. The first model list of essential drugs (EDL) was
prepared by an Expert Committee and published by WHO
in 1977 and now includes 306 active ingredients (11th
edition of November 1999).] The list does not exclude
all other medicines but rather focuses on therapeutic decisions, professional training, public information. and
financial resources. The essential medicines represent the
best balance of quality, safety, efficacy, and cost.

Virtually no system in the world offers unlimited access

to all medicines and vaccines, even in the wealthiest
countries. Careful selection of priority medicines is indispensable and should be based on considerations of quality, safety, efficacy, cost-effectiveness, and local appropriateness. The concept of essential medicines (a term that
describes all pharmaceutical preparations used in clinical
healthcare practice) is that a limited number of carefully
selected medicines based on agreed standard treatment
guidelines leads obviously to a better supply of medicines,
to more rational prescribing and dispensing, and to the
most cost-effective use of health resources. In developing
countries, the essential medicines concept has also provided a means by which governments and donor agencies
can plan and monitor drug procurement. It is within this
framework that in 1978 a conference on primary healthcare (PHC) was jointly convened by WHO and UNICEF
at Alma-Ata, Kazakhstan to confirm that the provision of
essential medicines was one of the eight components of
PHC. Essential medicines are defined as those that sa908

tisfy the healthcare needs of the majority of the population

and they should therefore be available at all times in
adequate amounts and in appropriate dosage forms and at
a price that individuals and the community can afford.
Their safety and relative cost-effectiveness are also major
considerations in the choice.]
Since the first WHO EDL was published 25 years ago,
more than 146 countries have adopted national EDLs, the
WHO list serving as a model and not as a global standard.
The list is biennially updated by a WHO Expert Committee, and the current eleventh revision (November 1999)
includes 306 active ingredients (medicines, vaccines, contraceptives, insect repellents, and diagnostic agents) specified by international nonproprietary names (INN) or generic names-50% more drugs than in 1977 and of which
250 are included in WHO clinical guidelines. The list is
divided into a main list, a complementary list, and there
is a separate category of reserve antimicrobials. However, selection and dissemination of the list are not by
themselves sufficient for ensuring rational drug use. Guidelines (e.g., clinical therapeutic guidelines, guide to good
prescribing, WHO ethical criteria for medicinal drug promotion, drugs and therapeutic committee), professional
training (e.g., training courses organized by the International Network for rational use of drugs, INRUD, Washington, D.C.), formulary manuals and independent drug
information centers (e.g., drug bulletin publications with
the aid of the International Society of Drug Bulletins,
ISDB) are needed for health professionals to put lists into
clinical practice.
Over the past 25 years, the model list has led to a
global acceptance of the concept of essential medicines as
a powerful means to promote health equity. By the end of
1999, 156 WHO member states had official essential medicines lists, of which 127 had been updated in the previous five years.

The selection of essential medicines is one of the seven

key components of a national drug policy (the other comEncyclopedia of Clinical Pharmacy
DOI: 10.108l/E-ECP 120014641
Copyright C 2003 by Marcel Dekker, Inc. All rights reserved.

909

World Health ~ ~ g a n i z a Essential

~ i o ~ Drug List

ponents being legislation, regulation and guidelines, access to essential medicines, quality assurance, rational use
of medicines, research, and human resources development). Usually, market approval of a pharmaceutical product is granted by drug regulatory authorities on the basis
of efficacy, safety. and quality, and rarely on the basis of
comparison with other products already on the market or
cost. Different criteria are used for the selection of essential medicines; e.g., medicines with adequate evidence
of efficacy and safety; relative cost-effectiveness with
comparisons between medicines (comparative efficacy
and safety, meta-analysis) and considerations of the total
cost of the treatment; pharmacological criteria (e.g., pharmacokinetic properties, bioavailability, galenic stability);
and formulations as single compounds, with fixed-ratio
combination products being acceptable only when the
combination has a proven advantage (e.g., therapeutic effect, adherence to treatment improvement).
There may still be oppositions to the use of the essential medicines list. Physicians may see it as questioning their prescription freedom, pharmacists may be worried about the financial implications, while manufacturers
may fear a market erosion, and consumers may think
that they are being offered second-rate cheap medicines.
These concerns must be considered and addressed, and
this is why the selection process should be consultative,
and why education plays an important part. In fact, an
essential medicines policy is nothing but an extension of
the selective exercise carried out by the state, on behalf
of the rights a community has to useful and safe products, to identify medicines that deserve marketing approval. The principle of convenience is under consideration in an increasing number of countries, especially
as the pharmaceutical industry becomes more prolific,
more complex, and uses products that are increasingly
powerful and, consequently, more hazardous.

mentation and compliance], These problems are greatest

in low-income countries, but middle- and high-income
countries are also increasingly facing difficult therapeutic
and economic decisions.
To ensure access to essential medicines, WHO has
defined a strategy by focusing on four key objectives:
rational selection and use (through a strengthening of
links between WHO EDL and standard therapeutic guidelines for priority diseases); affordable prices (through
good procurement practices and indicative cost information policies, and TRIPS safeguards as parallel import and
compulsory licensing for new essential medicines); sustainable financing, national spending on pharmaceuticals
varying from $2 to $400 per capita and per year (through
public funding and a health insurance scheme to maximize risk-pooling and equity shifts); and reliable health
systems ensuring a proper diagnosis and treatment and a
responsible supply system.
Despite the obvious medical and economic importance
of essential medicines, there are still problems with lack
of access, poor quality, and irrational use. In many health
facilities in developing and in developed countries, essential medicines are not used to their full p~tential.'~'
While the EDL is regarded as a key aspect of global
health and economics, the WHO EDL is, for the past few
years, at the center of debates with respect to access issues
(such as new essential medicines for HIV/AIDS, tuberculosis, and bacterial infections) and availability issues
(such as the lack of pharmaceutical research and development for tropical diseases, most of the current tropical
pharmacopoeia having been driven by colonization requirements during the first part of the 20th ~ e n t u r y ) . ' ~In'
2001, still one-third of the world's population (over 50%
in the poorest part of Africa and Asia) does not have
regular access to the most vital essential medicines.

EF
AC

ESSE

Despite important achievements, the lack of regular access to essential medicines still remains a major health
problem, recently highlighted by the magnitude of the
HIV/AIDS pandemic [e.g., in the 11th EDL, while 15
drugs of importance to HIV-related opportunistic infections are present, only two antiretroviral drugs (ARVs) are
listed for the prevention of mother-to-child infection, and
no ARVs are listed for the HIV treatment itself because of
their high costs and prerequisites for treatment imple-

1. WHO. The WHO essential drugs list. URL: www.who.int/

medicines/edl.html (accessed on Oct. 2000).
2. WHO. The Use of Essential Drugs. In 6th Reporf of the
Expert Committee; WHO Technical Report Series, World
Health Organization: Geneva, 1995; Vol. 850.
3. WHO. WHO Medicines Strategy: Framework for Action in
Essential Drugs and Medicines Policy, 2000-2003; World
Health Organization: Geneva, 2000, (WHO/EDM/2000.1).
4. PCcoul, B.; Chirac, P.; Trouiller, P.; Pinel, J. Access to
essential drugs in poor countries. A lost battle? JAMA, J.
Am. Med. Assoc. 1999, 281, 361-367.

AACl. &e Anierican Aswctxion or Colleges

of Phnrmacy
Abbott Total Quality Pain Maiiagcment. 643
Abhrehiated New Drug Application, 380
Aboriginal peoples. ethical issues. 879
Abstracts. phat-maceutical. Arncrican Society of
IIealth-Sy\teni Ihat-cnncists. 487
ACA. SW American Collegc of Apothecaries
Academia
carecrs options. clinical phal-macy
mentist. 179
clinical pharmacy careers in, I 5
academic \ites, description of; 7. - 4
activities, 1
career ladder, 4
degree, 4
cxpcrieiice requil-ed, 4
~

rilctiity, 3

options in, 1-3

r c w r d system, changes in. 2
tenut-e \ystern. changes in. 2
training, 4
transition in academia. I -3
drug information phariiracy pi-actice in. 29 I
Academy of Managed (iirc Phai-macy. 6-7,
23 I . 270. 496
governance. 6
initiatives. 7
meetings. 7
mission \t;itcincnt. 6
organir;~tionalstructure. 6
vision \tatcrncnt, 6-7
Access to healthcare. 41 1
Access to phai-inaccutical\, 35
Accidents, as cause of death, 404
Account manager. profesealiot1;rI
opportunities. SO2
American Collegc of Cliiiical
Pharmacy
Accreditation
American Council on 2h;it-ni;iceuiical
Education, 8
defined, 224, 230
Accreditation of liealtli-Care Organi/ations.
Joint Corninission for, 493 -495
acci-editation process utmdards, 495
accreditation \tatus, 493 -495
background. 493
Acctatninophen
advcrsc drug reaction\, 29
cytochrome P450, 247

.4cetohexamidc. adi,erse drug reaction, 30

Acctylatorn, drug reaction, 29
ACE. See Adtninistration for Children
m c l Families
ACPE. S c v Amet-ican Council 011
Iharniaceutical Education
Acquired iinnitiIl[jdcficiency syndrome.
Src. AIDS
ActiMcd Lahoratorie\, 141
Acyclot i l . 587
Adcnovirus. viral transfer techniques, 368
assessing, 12- 13
direct methods, I 2
indirect rncthods. 12- 13
children. 17- I8
chi-onic d i x a s c s , 18-19
coinmuiiity resources, 17
cultural differciiccs and, 17
IlldcrCare Patient Ikhcation Series, 15
elderly, 15- I6
cognititc liinitations, 15
limiteil iicce\s to health cat-c, I5
phy\ical impairmcnts. 1;
polyph;irmacy, 15
risk factor\ for nonadherence. 15
ethnic minorities, 16- 17
factors affecting. 13
fear tactics, 14
follolr-up, 14
hypertension. 18- 19
implement t-ewarti system. 14
infot-rncd tnctlication consumer, pateint a s , 14
lowliteracy patients, 16
National Council on Patient Infot-ni;ltion
and tiducation, I S
iionadhcrence
as behavioral diwrder, 1 1
defined. 10 1 1
patient-focused interventions for, 13- 14
risk lactors for. 1 I
scope of prohlem, 10- I I
patient goal\. 14
patient-centered adherence pnradigni. 1 I
p q i n e n t for adhcrcncc scrvicm, 20
Pediatric Mcdication Text. IS
Peter Lani). Ccntcr fot- Drug Thcrapy and
Aging, 15
phai-macothcrapy, enhancing adhcrencc to,
14-18

resources for improving, 15

sclf-efficacy, 14
space considerations, 20
special populations, 14- 18
type 2 diabetes, 19
Adiniiiistration. drug, routcs of, 85
Administration for Children and Families, 254
Adiiiiiiistration on Aging, 254
Advance Care, 141
Advanced cardiac life support, 125
Advanced professional educational programs,
556
Adverse drug reactions. 2 3 -34
cla\siiication sy\tcma, 23-24
clinical pharmacy. economic analysis,
307-321
definitions, 23
dr-ug-nulrient interactions, 30
factors predisposing to, 24-28
delivery system, 24
diseases, influcncc of, 27
dosage form. 24
t h e , 24
drug-related factors, 24-25
hypoalbuminemia. conditions associated
with, 26
inleractions between drugs, 24-25
patient-related factors. 25 -28
concurrent diseases, 25
gender. 28
genetic factors. 26-28

herbal therapies usc, 28

multidrug usc, 28
nutrition, 28
pediatrics, 25
renal disease, 26
pediatrics, 26
genetic factors, 20
gcriairic age-related changes,
pharrnacokinctic, 25
herbal medicines. 3 I
hutnan reliability
curve. 539
enhancing, 539-542
incidencc. 24
manageable hehaviors
at-risk behavior, 540- 54 1
high-culpability behavior, 541 -542

911

Index

912
Adverse drug reactions (cont.)
imperfect behavior, 540
Naranjo causality algorithm, 32
pharmaco-epidemiologic studies, 30-3 1
spontaneous reporting, 30-31
prevention, 32-33, 533-544
manageable behaviors, 540
medication-use cycle. 533-535
outcomes-measurement approach, 538 -539
preventable patient harm. scientific
investigation, 536-539
process-improvement approach. 536-538
role of pharmacist, 542-543
reporting systems, 28 -32
screening methods, 30
Affordability of health care services, elderly
and. 15
Afiican Americans, Plzarnzacokiizetics and Drug
Interactions in Elderly and Special
Issues in Elderly Aj%can-American
Populations. 481
Agency for Health Care Policy and Research,
417
Agency for Healthcare Research and Quality,
35-38, 254. 417, 621
Agency for Toxic Substances and Disease
Registry, 254
Age-related changes
geriatric, pharmacokinetic, 25
pharmacokinetics and, 25
Age-related risk factors, pediatrics adverse drug
reactions, 26
AHCPR. See Agency for Health Care Policy
and Research
AHRQ. See Agency for Healthcare Research
and Quality
AIDS
as cause of death, 404
Confronting AIDS: Direction f o r Public
Healtli, Health Care, and Research,
48 1
No Time to Lose: Getting More from HIV
Prevention, 48 1
AIDS group. Cochrane collaborative. 183
Airways group, Cochrane collaborative. 183
Alaska, pharmacy practice legislation, 272
Albuterol, 671
Alcohol
drug reaction with, 30
excipient in drug, 95
Allergic reaction, to drug, 23
Allergies, medication, 286-287
All-inclusive care for elderly (PACE) programs,
managed care, clinical pharmacy
careers in, 504
Allwin Data. software, 216, 218
Aloe, adverse reaction to, 31
Alzheimer's disease, 588
gene therapy, 376
Amantadine, 585, 588
Ambulatory care
clinical pharmacy careers in, 39-42
degrees, 40
job activities, 39-40

long-term opportunities, 40-41

salary range, 40
site description, 41
training, 40
work settings. 39-40
fellowships in, 356
Ambulatory clinic, university-affiliated, clinical
phaimacy, economic analysis,
307 - 32 1
AMCP. See Academy of Managed Care
Pharmacy
American Academy of Clinical Toxicology,
761-762
American Academy of Pain Management, 643
American Academy of Pain Medicine, 643
American Association of Colleges of Pharmacy,
210, 231, 270, 496
appointed Commission to Implement Change,
210
Commission to Implement Change, 210
Janus Commission, 491 -492
history. 491
members of, 492
mission, 491 -492
American Association of Phannaceutical
Scientists
Pharmacokinetics. Pharmacodynamics and
Drug Metabolism Section, 166
Population Pharmacokinetics and Pharmacodynamics Focus Group, 166
American Association of Poison Control
Centers, 761
American Cancer Society, 621
American Chronic Pain Association. 643
American College of Apothecaries. 231, 496
American College of Clinical Pharmacy, 43-44,
188-198, 231, 270, 475, 496
clinical pharmacist evaluation, 154- 160
collaborative drug therapy management.
188-198
Commission to Implement Change in
Pharmacy Education, 210-213
governance, 44
organization, 43
advocacy, 44
education. 44
membership, 43
professional leadership, 44
programs. 44
publications, 44
Pharmacokinetics Dynamics Practice
Research Network, 166
position statement, 188
American Council on Pharmaceutical Education,
8-9,45-47, 231, 270,496
accreditation, 8, 45
continuing education accreditation program,
45-46
current initiatives, 47
meetings, 47
mission, 46-47
organizational structure, 46
professional degree programs, 45
"Standards 2000," 8-9

Aniericaiz Journal of Health-System Pharmacy,

48-49, 57
history. 48 -49
objectives, 48
American Journal of Pharmaceutical Education,
50
American Medical Informatics Association, 293
American Pain Foundation, 643
American Pain Society, 621, 643
Anzerican Pain Societ): Bulletin, 450
American Pharmaceutical Association, 51 -52,
231. 270, 496
current major initiatives, 52
history, 51
meetings. 52
mission, 52
organizational structure, 5 1-52
American Society for Clinical Pharmacology
and Therapeutics. Pharmacokinetics
and Drug Metabolism Section,
166- 167
American Society of Addiction Medicine, 643
American Society of Anesthesiologists, 643
American Society of Clinical Oncology, 621
American Society of Consultant Pharmacists,
53-55, 232, 270, 496
advocacy. 54-55
consultant pharmacy practice, 53-54
education, 54
mission, 55
practice resources, 55
publications, 55
senior care pharmacy, 53
American Society of Health-System
Pharmacists. 56-57, 232, 270,
496, 621, 622
American Journal of Health-System
Pharniacy. 57
best-practices documents, 79-81
access to, 81
Clinical Practice Section, 293
clinical skills programs. 57
educational resources, 57
Handbook on Injectable Drugs. 57
history, 56
International Pharmaceutical Abstracts, 57,
487
Medication Teaching Maizual, 57
membership, 56-57
midyear clinical meeting, 475
publications, 57
Supplemental Standard and Learning Objectives for Residency Training, 166
American Thoracic Society, 474
American Zoo and Aquarium Association, 775
AMIA. See American Medical Informatics
Association
Amikacin, AIDS, 442
Aminoglycosides
AIDS, 442
drug reaction, 27
Amphotericin B, AIDS, 442
Amyotrophic lateral sclerosis, 585, 588
gene therapy. 376

Index
Analgesia, 587, 754
drug reaction, 27
Analytical toxicology, 773
Analyzing and Recording Drug Information
Request, 293
ANDA. See Abbreviated New Drug Application
Anemia of end-stage, gene therapy, 376
Anesthesia group, Cochrane collaborative. 183
Anesthetics
adverse drug reaction, 29
adverse drug reactions, 29
Anthrax Vaccine Immunization Program, 776
Antibiotic rotation, 58-62
antimicrobial rotation. 58
impact of, 59-61
elements of, 58-59
erythromycin, effect on group A
streptococci, 60
resistance
pathways for, 59
variables involved in, 59
role of, 61
Antibiotics, 587
Antibodies, 870
Anticholinergics. 587, 588
drug reaction, 27
Anticoagulants, drug reaction, 27
Anticoagulation, 588
Anticoagulation clinical pharmacy practice,
63-70
British Committee for Standards in
Haematology, guidelines, 67
certification, 66-67
Consensus Conferences on Antithrombotic
Therapy, 67
Consensus Guidelines for Coordinated
Outpatient Oral Anticoagulation
Therapy Management, 67
cost effectiveness, 65
credentialing, 66-67
deep vein thrombosis, 64
description of. 64-65
legal issues, 68
Managing Oral Anticoagulation Therapy,
Clinical and Operational
Guidelines, 67
networking opportunities, 68
opportunities in, 64-66
patient satisfaction, 65
resources, 67 -68
safety, 65
training, 66-67
in United Kingdom, 64
in United States, 64
Anticoagulation Forum, 232, 270
Antidepressant medication management,
effectiveness of, studies, 565
Antiepileptic drug, 585, 587, 588
therapy, 586
toxicity, 586
Antihypertensives, 588
Antiinflammatory drugs, adverse drug reaction,
27
Antilymphocyte gamma globulin

913
horse, 870
rabbit, 870
Antimetabolites, 870
Antimicrobial Agents and Chemotherapy, 472
Antimicrobial rotation. 58
impact of. 59-61
Antimicrobial Therapy and Vaccines, 473
Antineoplastics, unlabeled indications, drug use
for, 551
Antiplatelets, 587, 588
Antipsychotics, 588
unlabeled indications, drug use for, 551
Antiretroviral Pregnancy Registry UCSF
On-Line information, 896
Antisecretory medication, 588
Antispasmodics, 587, 588
Antithrombosis. 122
Antivenom Handbook for Australia. 775
Anxiety and neurosis group, Cochrane
collaborative, 183
AOA. See Administration on Aging
AppDC, software, 216, 218
Approved Drug Products with rapeutic
Equivalence Evaluations, 380
Arizona, pharmacy practice legislation, 272
Arkansas
pharmacy practice legislation, 272
regulations governing prescribing, 190
Arthritic joint pain. 585
ASCCP. See American College of Clinical
Pharmacy
ASCO. See American Society of Clinical
Oncology
ASCP. See American Society of Consultant
Pharmacists
ASHSP. See American Society of
Health-System Pharmacists
Aspirin, 587
adverse drug reactions, 29
drug reaction, 27
Asset forfeiture program, Drug Enforcement
Agency, 282
Assisted living facilities, diabetes care, 257-258
Association Foundation Executive, Director of
Research Institute Attorney, 819
Association of Asthma Educators, 270
Association of Faculties of Pharmacy of Canada,
71-74
initiatives, 71
meetings, 71 -72
mission, 71 -72
organization structure, 71
Asthma, 814
drug reactions and, 27
ATIS. See HIV/AIDS Treatment Information
Service
Atrial fibrillation, 585
ATS. See American Thoracic Society
ATSDR. See Agency for Toxic Substances and
Disease Registry
Attention-deficit disorder, 585
Audit, principal investigator, clinical pharmacist
as, 153
Australasian Cochrane Centre, 185

Australia
Pharmaceutical Benefits Scheme, 688-691
approval of medicines, 688
brand price premiums, 689
medication management program, 690
pharmacy development program, 690-691
prescribing, 688-689
prices, 689-690
therapeutic group premiums, 689-690
Society of Hospital Pharmacists of, 851 -853
Therapeutic Guidelines Limited, 857- 859
current initiatives, 858-859
history. 857
major directions, 859
mission, 858
objectives, 858
organizational structure, 857- 858
Australian Adverse Drug Reaction Advisory
Committee, 73-74
data usage, 74
membership, 73
reporting reactions to, 73-74
Australian Journal of Hospital Pharmacy, 852
Australian Medicines Handbook, 75 -77
content, 76-77
content features, 76
editorial advisory board, 77
history, 75
philosophy, 75
review, 77
types of information, 76
Automated delivery, hospital pharmacy practice
in, 456
Avocet Medical, Inc., 141
AvoSure Pro, 141
Azathioprine, 870

Back group, Cochrane collaborative, 183

Back pain, 587
Barbiturates. as cytochrome P450 inducer, 247
Basiliximab, 870
Bayer DCA 2000. 141
Behavioral disorder, nonadherence in
pharmaceutical care as, 11
Bells palsy, 587
Benzocaine, adverse drug reaction, 29
Best-practices documents, American Society of
Health-System Pharmacists
access to, 81
development, 80-81
guidelines, 80
position statements, 80-81
purpose, 79
topics, 79
Beta agonist, 585
tremor, 585
Beta blocker, 588
after heart attack, effectiveness of, studies,
565
drug reaction, 27
Beta interferons, 587, 588
Bioabsorption, oral drug, 88-92
physiologic considerations, 88-92

914
Bioal ailability, 92-93
bioequix alence. 97-98
Bioequivalence. 97-98
Biopharmaceuticals. 82- 102
bioavailability. 92 -93
bioequivalence, 97 -98
bioequivalence, 97
biowai1ers. 101
cell membrane passage
carrier-mediated transport, 88
passive diffusion. 84-88
vesicular transport. 88
classification system, 99- 101
disintegration. 92-93
dissolution. 101
formulation factors. dissolution, 95-96
generic drug products, 97-98
oral drug absorption, 88-92
blood perfusion. gastrointestinal tract;
89-91
food, effect of. 91 -92
gastric emptying time, 89
gastrointestinal motility. 89
intestinal motility, 89
physiologic considerations. 88-92
rate-limiting, 84
particle size, 94
permeability class, I00
pH. 93-94
physiologic factors affecting. 84-88
cell membrane passage, 84-88
polymoiphic crystals, 94-95
postapprobal change levels. 100
postapproval changes, 101
product design. 82-84
scale-up. 101
solubility. 93. 99- 100
i n v i m dissolution testing. 96-97
in iitro performance. 98-99
in vitro-it7 vivo correlation. 98-99
Bioscanner 1000, cholesterol monitoring test.
466
Biotechnology industry, careers options, clinical
pharmacy scientist, 179
Biowaivers, 101
Bipolar disorder, 585
Bleeding. limiting antiplatelet drug use, 585
Bleeding disorders. drug reactions and. 27
Blockers. cytochrome P450, 247
Blood concentration curve. 381
Blood dqscrasia. 585
Blood perfusion. gastrointestinal tract, 89-91
Blood pressure, controlling, effectiveness of.
studies, 565
Board certification. See Certification
Board of Pharmaceutical Specialties. 103 - 105,
228. 232. 270
added qualifications. 104
certification. process, 104- 105
mission. I03 - 104
specialties. 104
Boehringer Mannheim Corp.. 141
Bone marrou transplant, 106- 110
clinical pharmacy opportunities, 106- 108

Index
health outcome, 109
model clinical practices. 108- 109
clinical-based practice, 109
hematopoievis chart. 109- 110
networking. 110
research-based practice, 108- 109
tools. 109- 110
pharmacists responsibilities, 107
BPS. See Board of Pharmaceutical Specialties
Bradycardia. drug reactions and, 27
Breast cancer
gene therapy trials, 374
screening, effectiveness of, studies, 565
Breast cancer group, Cochrane collaborative,
183
British Committee for Standards in
Haematology, guidelines, 67

CA-A Cancer J014rnd f o r Clinicians, 623

Caffeine, 754
cytochrome P450, 247
drug reaction with, 30
Calcineunn, 870
inhibitors, drugs interacting with, 870
Calcium channel blockers: 588
Calcium regulation. abnormality of, drug
reaction, 29
California
pharmacy practice legislation. 272
regulations governing prescribing, 190
Call center pharmacist, professional
opportunities. 502
Cam Commerce Solutions, software. 216. 218
CAMIPR. See Consortium for Advancement of
Information Policy and Research
Campus. National Institutes of Health, 576
Canada; health care systems, 390
Canadian Cochrane Centre, 185
Canadian Hospital Pharmacy Residency Board,
111
Canadian Pharmacists Association/Association
des Pharmaciens du Canada,
112- 114
e-business, 113-114
initiatives. 113 - 114
pharmacist shortage, 113
prescribing authority, 113
prib acy legislation, 113
third-party payer issues, 113
meetings. 114
mission, 112-113
organizational structure, 112
Pharmacy Electronic Communications
StandardDJational +Claims
Standard Initiative. 113
publishing. 114
Cancer
as cause of death, 404
gene therapy. 373
specialty pharmacy practice. 61 1-626
anticancer therapy, outcomes related to,
618
chemotherapy order verification, 612

clinical pharmacy opportunities, 61 1-614

clinical research, 617-618
documented benefits, 618-620
drug administration policies, 613
drug handling, 612-613
drug information, 614, 617
education, 614
guidelines, 620-622
inpatient care practice roles, 615-616
investigational drug use, 617
medication order review, 612
model clinical practices, 614-618
outpatient care practice roles, 616-617
patient care problems, 613
patient care services. 620
patient education, 613
patient monitoring. 613-614
practice guideline development, 618-619
reimbursement, 620
resources for, 620-623
roles. 612
specialist interventions, 619-620
summary of interventions. 619
transitional patient care practice roles,
616
Cancer Care Ontario. 621
Cancer Chemotherapy and Biotherapy:
Principles and Practice, 622
Cancer Chemotherapy Handbook, 622
Cancer Chemotherapy Pocket Guide, 622
Cancer Control Journal, 623
Cancer pain, Talarian map. 450
Cancer Principles and Practice of Oncology,
622
Cancer Therapy Evaluation Program. 622
Cancer Trials Support Unit of National Cancer
Institute. 622
Capsacian, 588
Capsule, oral administration of, processes
following, 86
Carbamazepine, 870
adverse drug response. 29
pediatric pharmacokinetic data, 665
Carbidopa, 588
Cardiac arrest. 115-118
Cardiology, 119- 126, 356. See also Cardiac
arrest
acute care, 120-121
acute coronary syndromes, 124- 125
advanced cardiac life support, 125
antithrombosis. 122
atrial fibrillation. 125
chronic heart failure, 121- 122
clinical pharmacy guidelines, 124- 125
dyslipidemia, 121, 125
fellowships in, 356
gene therapy clinical trials, 375
heart failure, 125
home care. 442-443
hypertension, 121, 125
networking opportunities, 123- 124
outpatient, 121 - 123
professional opportunities, 124
stable angina, 125

Index
Cardiovascular disease
drug reactions and, 27
gene therapy, 375
Cardiovascular system, neurology specialty
pharmacy practice, 585
Career opportunities. 428-431. See also under
specific career
in academic clinical pharmacy, 1-5
academic sites, description of. 3-4
activities, 1
career ladder, 4
degree, 4
experience required, 4
faculty, 3
training, 4
transition in, 1-3
academicians. evolution of, 3
higher education, 2
reward system. changes in, 2
tenure system, changes in, 2
acute care, 428
ambulatory care, 40-41. 428
anticoagulation, 64- 66
bone marrow transplant, 106- 108
cardiology. 124
clinical pharmaceutical sciences, 179
in clinical pharmacy, long-term care, 498-499
consultant pharmacist services, 498
history. 498-499
job settings. 499
professional opportunities. 499
role of consultant pharmacists, 498
training, certification requirements. 499
clinical pharmacy careers, 40-41
community pharmacy, 428
drug information pharmacy practice. 290
drug information service, 428
government, 385-388
home care. 428, 437-438
hospice, 449
infectious diseases, 470-471
long-term care. 428
managed care pharmacy practice, 506-509
management of pharmacy s a k e s , 428-429
palliative care: 449
primary care. 40-41
range of. 428-429
scientist. clinical pharmacy, 179 - 180
specialty practice. clinical pharmacokinetics,
161-164
therapeutic drug monitoring service, 428
work settings, 429
general clinical practice model, 429
outpatient pharmacy, 429
Carepoint. Inc., software. 216. 218
Carrier-mediated transport process, 88
Causes of death in U.S., 404
CBIAC. See Chemical and Biological Defense
Information Analysis Center
CCGP. See Commission for Certification in
Geriatric Pharmacy
CDC. See Centers for Disease Control
Cell membrane passage, 84-88
carrier-mediated transport, 88

915
passive diffusion. 84-88
vesicular transport, 88
Cellulose acetate phthalate, excipient in drug, 95
Centers for Disease Control, 252, 474, 896
careers, 179, 386
research and research policy, 179
Centers for Medicare and Medicaid Services,
254
Centre Cochrane Francais, 185
Centro Cochrane do Brasil, 185
Centro Cochrane Iberoamericano, 185
Centro Cochrane Italiano, 185
Cerebrovascular disease, drug reactions and, 27
Certificate, defined. 224, 230
Certificate training program, defined, 230
Certification
anticoagulation clinical pharmacy practice,
66-67
Board of Pharmaceutical Specialties,
104-105
defined, 224, 230
disease management, 268-269
infectious diseases, 469
long-term care, clinical pharmacy careers in,
training. 499
Certification bodies. 23 1
Certified. defined. 230
Certified Regional Poison Information Center,
762
Cervical cancer
gene therapy trials, 374
screening. effectiveness of, studies, 565
Charcoal-broiled meat, as cytochrome P450
inducer, 247
Chemical and Biological Defense Information
Analysis Center. 776
Chemical Weapons Conventions Web SiteOrganizations for Prohibition of
Chemical Weapons, 777
Chemotherapy Sourcebook, 622
ChemTrack AccuMeter, 141
Chicken pox, 712
Childhood Vaccine Injury Act of 1986,
559-563
adverse events, vaccine, 559
childhood diseases. vaccination against, 559
documentation, 561
historical advancements, 559
immunization practice, pharmacy-based, 56 1
liability. 561
manufacturer liability, 559-560
National Vaccine Injury Compensation
Program, 560-561
protection under NCVIA. 561
reporting. 561
Vaccine Injury Act of 1986. 560-561
vaccine injury table. 560
Children, nonadherence to medical care, 17- 18
Chinese Cochrane Centre, 186
Chloramphenicol. adverse drug reaction, 29
Chloroquine. adverse drug reaction, 29
Chlorpropamide. adverse drug reactions, 30
Choice, Medicare, 514
Cholestech, 141, 466

Cholesterol monitor
CLIA waived status, 466
Lifestream Technologies, 141
Cholestyramine, 870
Cholinesterase inhibitors, 588
Chronic diseases. nonadherence to medical care
in, 18-19
Chronic heart failure, 121 -122
Chronic medical problems, 287-289
Chronic pain services, pain management,
639 - 64 1
Cidofovir. AIDS, 442
City of Hope Palliative Care Resource Center,
643
Claims manager, professional opportunities, 502
Clarithromycin, 870
Clinical evaluation, drugs. 127- 138
drug development team members
nonscientific personnel, 130
pharmacists, 129- 130
physicians. 128- 129
roles of, 128-130
scientists, 129
ethical issues, 136- 137
global planning. 135- 136
marketing input, 135
protocol, 133- 134
stages in, 130-133
phase 1, 131-132
phase 2, 132
phase 3, 132-133
phase 4. 133
Clinical Infectious Diseases. 472
Clinical Laboratory Improvement Amendments
of 1988, 139-143
history. 139- 140
regulatory framework, 140- 142
moderate-, high-complexity tests,
141-142
patient test management, 142
personnel, 142
proficiency testing, 142
quality assurance, 142
quality control, 142
waived tests, 141
relationship to pharmacy. 140
Clinical Oncology, 622
Clinical Pharmacology Drug Database, 774
Clinical Pharmacy Practice Guidelines,
Society of Hospital Pharmacists
of Austrah, 170- 173
Clinical privileges, defined. 230
Clinical specialist, professional opportunities,
502
Clinical trial
design, ethical issues, research, 339-340
ethical issues, 879-880
ClinicalTrials.gov, 582
Clinicians Guide to Chemotherapy Pharmacokinetics and Pharmacodynarnics,
622
Clinics, diabetes care, 257
Clonazepam, pediatric pharmacokinetic data,
665

Index

916
Clopidogrel, 587
CMS. See Centers for Medicare and Medicaid
Services
CoaguChek PST, 141
CoaguChek S Systems Test, Roche Diagnostics,
141
Coccidiomycosis, with AIDS, 442
Cochrane centers, 181-182
information on, 185- 186
Cochrane Library, 181- 187
Cochrane centers, 181-182
Cochrane collaborative review groups,
182-184
Cochrane methods group, 184
collaboration structure, 181- 186
history, 181
steering group, 181
subscribing to, 184
Cochrane methods group, 184
Cognitive impairment group, Cochrane
collaborative, 183
Cognitive limitations, in elderly, adherence and,
15
Collaborative drug therapy management, 192
access to patients, 196
American College of Clinical Pharmacy,
188-198
position statement, 188
collaborative relationships, defining, 195
compensation, 196- 197
credentialing, 197
documentation of activities, 196
environment, 195- 196
federal government, regulations governing
prescribing, 191
health care, evolving view of, 193- 194
medical records, access to, 196
pharmacist prescribing in U.S., history of,
188-192
prescribing
defined, 194
evolving view of, 194-195
regulations governing pharmacist prescribing,
190-191
requirements for, 195- 197
Collaborative partnerships, 693
Collaborative practice agreements, 199-206
current pharmacy practice environment,
199-201
definitions, 199
types of, 201-206
Collaborative relationships, defining, 195
College of Psychiatric and Neurologic
Pharmacists, 207-209
initiatives, 208
meetings, 208-209
membership, 208
mission. 208
organizational structure, 207-208
Colon, drug absorption in, 90
Colon cancer, gene therapy trials, 374
Colorectal cancer group, Cochrane
collaborative, 183
ComCo Tec, software, 216, 218

Commission for Certification in Geriatric

Pharmacy, 229, 232. 270
Commission to Implement Change, 210-213
Commissioned Officer Student Training and
Extem Program, 387
Committee involvement, medical information,
industry-based, labeling,
promotional review committee, 528
Communication skills, scientist, clinical
pharmacy, 178
Communications, medical, clinical pharmacy
careers in, 519-524
income, 519-521
training, 522-523
Community hospital
clinical pharmacy, economic analysis,
307 - 32 1
university-affiliated, economic analysis,
307 - 32 1
Community pharmacy
clinical pharmacy, economic analysis,
307-321
diabetes care, 256-257
Community pharmacy practice, hyperlipidemia,
462-463
Community-based home care, 440
Competence
defined. 230
ethical issues, 878
Competency, defined, 23 1
Compliance, counseling for, 650
Computer links, hospice, 450
Computer software, 214-222, 456
associated performance-enhancement tools,
22 1
clinical software attributes, 221
confidentiality, 222
documentation, 220 - 22 1
hardware array, 215-220
hospital pharmacy practice, 456
InfoWin, 456
point-of-care software, 220
privacy, 222
recommendations. 222
security, 222
Confidentiality
ethical issues, 878-879
software, 222
Conflict of interest, ethical issues, 879
Confronting AIDS: Direction for Public Health,
Health Care, and Research, 481
Confusion, agents causing, 586
Congestic heart failure, 754
Consensus Conferences on Antithrombotic
Therapy, 67
Consensus Guidelines for Coordinated
Outpatient Oral Anticoagulation
Therapy Management, 67
Consortium for Advancement of Information
Policy and Research, 293
Consortium of Academic Health Centers for
Integrative Medicine, 484
Constipation, 585
Consumer, informed, pateint as, 14

Consumer behavior, health services research,

412
Consumers group, Cochrane collaborative, 183
Contact information program, Drug
Enforcement Agency. 282
Continuing education
defined, 231
medical information, industry-based, 529
Contraceptives, drug reaction, 27
Contract research organization, infectious
diseases, 471
Contracting. professional opportunities, 502
Corn oil, excipient in drug, 95
Coronary artery disease, 585, 814
Coronary syndromes, 124- 125
Corticosteroids, 870
adverse drug reaction, 27
drug reaction, 27
COSTEP. See Commissioned Officer Student
Training and Extern Program
Cost-minimization analysis, 307- 321
costs
analysis, 307-321
anticoagulation therapy, 65
clinical pharmacy, economic analysis,
307-321
clinical pharmacy services, evaluations of,
301-325
Spain, 459
Cranial nerves, 586
Credential, defined, 224, 23 1
Credentialing, 223 -232
American College of Clinical Pharmacy. 197
anticoagulation clinical pharmacy practice,
67
certificate training programs, 227
certification, 228-229, 230
certification bodies, 232
certifying agencies, 228 -229
collaborative drug therapy management, 197
Council on Credentialing in Pharmacy, 223
defined, 224, 231
disease management, 268 -269
education, 230
entering practice, and updating professional
knowledge and skills, 226
fellowships, 227
importance of credentials. 224
knowledge, enhancing, 226-227
Millis Commission and, 557
multidisciplinary certification programs, 229
pharmacy supportive personnel, 229-230
preparing for pharmacy profession, 225-226
regulation, 230
residencies, 227
skills, enhancing, 226-227
traineeships, 228
training, 230
updating professional knowledge, 226
Credentials, U S . pharmacy, 225
Crime Drug Enforcement Task Forces, Drug
Enforcement Agency, 282
Critical care, 837
fellowships in, 356

Index
Critical care pharmacy, 233-239, 240-245
activities, 237, 242-244
challenges of, 237-238
components of, 235
cuixnt practice, 234-235
historical background, 240-241
history of, 233-234
hospital services, 244
impact of, 236-237
knowledge base, 235-236
methods, 241-242
purpose, 241
research in critical care, 235
Cryptococcosis, with AIDS, 442
CTEP. See Cancer Therapy Evaluation Program
Cultural differences, adherence to medical care
and, 17
Curricula, pharmacy, design of, 555-556
Cyclosporine, 870
cytochrome P450. 247
Cystic fibrosis
gene therapy, 373
home care, 442
Cystic fibrosis group, Cochrane collaborative.
183
Cytochrome P450, 246-250
in drug-drug interaction, 248-249
gene polymorphism, drug response,
differences, 246-248
isoenzymes, 246
nomenclature, 246
noninvasive measurement of, 249
in systemic availability of drug, 248
Cytomegalovirus infection, with AIDS, 442

DAA Enterprises, software, 216, 218

Daclizumab, 870
Dairy products. drug reaction with, 30
Dapsone
adverse drug reaction, 29
hydroxychloroquine, adverse drug reaction,
29
Data collection forms, patient drug history, 289
Database manager, professional opportunities.
502
Datdpopulation manager, professional
opportunities, 502
Declaration of Helsinki, 341-342, 755
Deep vein thrombosis, anticoagulation, 64
Degrees
academic clinical pharmacy, 4
clinical pharmacy careers, 40
Dehydrogenase deficiency, drug reaction, 29
Delerium, 586
Delivery system, adverse drug reactions and,
24
Delphi, software, 216, 218
Dementia group, Cochrane collaborative, 183
Dementia, 586
Dental care, Medicaid usage. 516
Department of Health and Human Services,
251-255
agencies of, 25 1-254

917

Agency for Healthcare Research and

Quality, 254
Agency for Toxic Substances and Disease
Registry, 254
Centers for Disease Control and
Prevention, 252
Food and Drug Administration, 251 -252
Health Resources and Services
Administration, 253
Indian Health Services, 252-253
National Institutes of Health, 251
Substance Abuse and Mental Health
Services Administration, 253 -254
human services operating divisions, 254
Administration for Children and Families,
254
Administration on Aging, 254
Centers for Medicare and Medicaid
Services, 254
Office of Secretary of Health and Human
Services, 254
Program Support Center, 254-255
Department of Veterans Affairs, careers in, 385
Depression, 585, 815
anxiety, neurosis group, Cochrane
collaborative, 183
Deutsches Cochrane Zentrum, 185
Development, drug, team members
nonscientific personnel, 130
pharmacists, 129- 130
physicians. 128- 129
roles of, 128-130
scientists, 129
Developmental, psychosocial, learning problems, Cochrane collaborative, 183
Dexamethasone, 870
DIA. See Drug Information Association
Diabetes, 256-259, 585, 586, 813
assisted living facilities, 257-258
as cause of death, 404
clinics, 257
community pharmacy, 256-257
documentation forms, 258
drug reactions and, 27
effectiveness of, studies, 565
hospital pharmacy, 257
managed care, 258
nursing homes, 257-258
physicians offices, 257
prescription drug benefit administrators, 258
private practice, 257
product sales, 258
Dibasic calcium phosphate, excipient in drug,
95
Dietary Supplement Health and Education Act,
260-264
administration (Sections 8-13), 262-263
history of, 260
introductory sections (Sections 1-4), 260-261
marketing, labeling of dietary supplements
(Sections 5-7), 261-262
Dietary supplements, 774
categories of, 604
drug regulation, comparison of, 261

Diffusion, molecules, 87
Digital Simplistics, software, 216, 218
Digoxin, drug reaction, 27
Diphtheria, 7 12
Dipyridamole, 587
Direct patient care, professional opportunities,
503
Directions in clinical practice in pharmacy
(Hilton Head Conference), 265-266
Disease management, 267-275
certification, 268-269
credentialing, 268- 269
reimbursement, 269 - 27 1
resources, 270
scope of practice, 267-268
Disease Management Association of America,
270
Disease Management Purchasing Consortium
and Advisory Council, 270
Disintegration, absorption and, 92-93
Disposable IV equipment, pediatric dosing,
667-668
Dissolution, bioavailability and, 101
Disulfiram
adverse drug reaction, 30
as cytochrome P450 inhibitor, 247
Diuretics, drug reaction, 27
Divalproex sodium, 588
Diversion control program, Drug Enforcement
Agency, 282
DNA, viral transfer techniques, 368
Doctor of Pharmacy, 276-281
career opportunities, 280-281
curriculum, 278-280
history of, 276-278
Documentation
diabetes care, 258
from hospice care providers, 452
hyperlipidemia, 466
software, 220-221
Dopamine agonists, 588
Dopaminergic agents, 585
Dosage form, adverse drug reactions and, 24
Dose, adverse drug reactions and, 24
D.P. Hamacher, software, 216, 218
Drug Database at Pharmaceutical Information
Association, 774
Drug Enforcement Agency, 282-283
history, 282
programs, 282-283
Drug history, 284-289
compliance aids, 287
components of, 286-287
financial/insurance information, 286
patient, 284-289
acute, chronic medical problems, 287-289
caregiver/family meinber, 285
compliance, barriers to, 287
components of, 286-287
data collection forms, 289
healthcare providers, 285
immunizations, 287
interviewing patient, 285 -286
medical records, 285

Index

918
Drug history (cont.)
medication allergies. 286-287
medications, 287
patient data records, 284
patients, 285
pharmacy dispensing records. 285
setting. 285
social history. 287
sources of patient data, 285
special patient populations, 285-286
types of data, 284-285
objective data, 285
subjective data, 284-285
pharmacist-conducted. rationale, 284
Drug Information Association, 294
Drug Information Framework, 360
software, 360
Drug information pharmacy practice, 290-294
academic practice. 291
associations, 292
community. 290-291
government, 292
industry, 291 -292
managed care, insurance companies, 292
model clinical practices. 290-292
networking opportunities, 293 -294
professional opportunities, 290
resources, 292-293
Drug information specialist, professional
opportunities, 502
Drug Information-A Guide to Current
Resources, 293
Drug InformationPharmacoeconornics
Network, 293
Drug intolerance, defined. 23
Drug Price Competition and Patent Term
Restoration Act, 380
Drug samples. 295-299
alternatives to, 298
JCAHO criteria. compliance, 296
regulatory issues, 295
Drug surveillance, Spain, 459
Dmg use evaluation, clinical pharmacy.
economic analysis, 307-321
Drug-nutrient interactions, 30
Dry eyes, caused by anticholinergic medication
effect, 586
Duke University, health outcomes reasearce.
36
Duodenum, drug absorption in, 90
Dutch Association of Hospital Pharmacists, 825
Dutch Cochrane Centre, 185
Dynamics Practice Research Network,
American College of Clinical
Pharmacy Pharmacokinetics, 166
Dyskinesias, 588
Dyslipidemia, 121

Ear. nose, throat disorders group, Cochrane

collaborative, 183
Eatonform, software. 218
ECDIN. See Environmental Chemicals Data and
Information Network

Echinacea, adverse reaction to, 3 1

Economic evaluations o f clinical pharmacy
services, 301 -325
analytic methods, 304
cost-justification studies, 303
methods, 301-302
type of analysis, 302
Economic value. o f clinical pharmacy services,
307 -321
Edema, 585
Education, 556
home care, 437
hyperlipidemia, 464-465
infectious diseases, 469
medical information. industry-based, 529
Education, Pharmaceutical, American Council
on, 496
Eldercare Patient Education Series, 15
Elderly
adherence to medical care, 15-16
cognitive limitations. 15
physical impairments, 15
polypharmacy, 15
risk factors for nonadherence. 15
flu shots, effectiveness of. studies, 565
home care, 443
pain management, 641
Pharinacokinetics and Drug Interactions
in Elderly and Special Issues in
Elderly African-American
Populations, 481
Electrolyte/nutritional status, neurology
specialty pharmacy practice, 585
Electronic prescribing, 326-329
advantages of, 327
description of, 326
disadvantages of, 327-328
impact on practice. 328-329
information available. 326-327
prescription destination, 327
Emergency pharmacy services, 115-1 18
Emergency room. clinical pharmacy, economic
analysis, 307-321
EmergencyNET. 776
Emerging Infections: Microbial Threats to
Health in United States, 481
Employee education, medical information,
industry-based, 529
ENA.C.T. Total Cholesterol Test, cholesterol
monitoring test, 466
Encainide, cytochrome P450, 247
Encephalopathies, 586
Endocrine disorders, drug reactions and, 27
Endocrine disorders group, Cochrane
collaborative. 183
Endocrine system, neurology specialty
pharmacy practice. 585
Enteral nutrition, 458
drug reaction with, 30
Environmental Chemicals Data and Information
Network, 774
Environmental Protecton Agency, careers
options, clinical pharmacy
scientist, 179

Epilepsy, drug reactions and. 27

Epilepsy group, Cochrane collaborative, 183
Epoxide hydrolase, deficiency of, drug reaction,
29
Ergotamine. 588
drug reaction, 27
Erythromycin
as cytochrome P450 inhibitor, 247
effect on group A streptococci, 60
Esophagus. drug absorption in, 90
Essential Drug List, World Health Organization,
908 -909
Estrogen replacement therapy. 815
Ethanol, cytochrome P450, 247
Ethical Conduct for Research Involving
Humans. Tri-Council Policy
Statement. 876-881
Ethical issues. 330-334
aboriginal peoples, 879
classification of. 332-333
clinical evaluation, drugs, 136- 137
clinical trials. 879-880
competence, 878
conflict of interest, 879
data collection, 878- 879
decision making and, 330-331
definition of, 332
discrimination, 333
disease management, 271 -273
ethical problems. 331 -333
ethics review procedures, 877
gene therapy, 376-377
human genetics research, 880-881
inclusion/exclusion of populations, 879
informed consent. 877-878
informing potential subjects, 878
medication assistance programs, pharmaceutical company-sponsored, 532
negative discrimination. 333
personal interviews, 878-879
pharmaceutical outcomes. 704
pharmacotherapeutic decisions, 332
physician, pharmacist, patient, relationship
among, 33 1- 332
positive discrimination, 333
privacy, confidentiality, 878- 879
rationing, 333
relationship, between health professional,
patient, 330
research, 335-343
clinical trial design, 339-340
Declaration of Helsinki, World Medical
Association, 341 -342
drug therapy, 337
in emergency health situations, 878
historical perspective, 335 -336
human subjects, protection of, 336
individual, vs. social interest, 339
informed consent, 336-337
investigator independence, 340
moral principles, 337-339
Nuremberg Code, 341
scientific integrity, 340
study volunteers, payment to, 337

Index
Ethical issues (cont.)
secondary use of data. 879
unavailability of medication. 332-333
Ethnic minorities, adherence to medical care,
16- 17
Ethosuximide, pediatric pharmacokinetic data,
665
Etreby Computer, software, 216, 218
European Association of Poisons Centres and
Clinical Toxicologists, 762
European Society of Clinical Pharmacy.
344 - 347
activities of, 345-346
calendar of events, 347
clinical pharmacy, 345
conferences, 345
education. 345
executive committee, 346
general committee members, 346
goal, 344-345
international office, 347
members, 347
organization of. 346-347
related organizations, 345 -346
research, 345
research and education committee. 347
special interest groups, 347
symposia, 345
Evaluating Drug Literature, 293
Evaluation, clinical pharmacist. American
College of Clinical Pharmacy,
154- 160
Evaluations of Drug Interactions, 360
Evidence-based practice, 348-354
applying evidence. 350
challenges of, 351
clinical effectiveness, 35 1-352
criticisms of. 350-351
implementation, 352-353
incomplete evidence, 35 1
number needed to treat. 350
pharmacist's role, 352
relative risk, 349
resources for, 352
understanding evidence, 349 -350
web sites, 352
Evolution. of academicians, 3
Excipients
effect on pharmacokinetics, 95
in liquid drug products. 95
solid drug products, 95
Exclusion of populations. ethical issues, 879
Expenditures for pharmaceuticals, reduction
of, 35
Experience required, in academic clinical
pharmacy, 4

Faculty, academic clinical pharmacy, 3

Family environment, home care, 440
Family medicine, fellowships in, 356
Family planning. Medicaid usage, 516
FDA. See Food and Drug Administration
FDAMA. See Food and Drug Modernization Act

919
Fear tactics, nonadherence in pharmaceutical
care and, 14
Federal Bureau of Prisons, careers in, 387
Federal government regulations governing
prescribing, 191
Fellowships, 355-357
applicant requirements, 356
in clinical pharmacology, 356
defined, 231
definitions, 355
experience of. 356
fellowship. defined, 355
guidelines, 355-356
preceptor qualifications, 356
resource, 356-357
training program requirements, 356
FEMA Rapid Response Information
System, 776
Fertility group, Cochrane collaborative, 183
Fertility regulation group, Cochrane
collaborative, 183
Financial information, patient drug history, 286
Financing
health care, 401-403
healthcare, 410-41 1
First DataBank, Inc.. 358-361
drug knowledge bases, 359
drug interactions, 359
patient education, 359
prescriber order entry, 359
Evaluations of Drug Interactions, 360
future needs, 361
integrated content software, 359-360
Drug Information Framework, 360
Rx InHand, 360
RxWeb, 360
locations, 361
mission statement, 358-359
Nutritionist Pro, software, 360-361
reference products, 360
software, 216, 218
specialty software, 360-361
Florida
pharmacy practice legislation, 272
regulations governing prescribing, 190
Flu, as cause of death, 404
Flu shots, for older adults, effectiveness of.
studies, 565
Fluid, neurology specialty pharmacy practice,
585
Fluvoxamine, as cytochrome P450 inhibitor, 247
Folic acid during pregnancy, 585
Follow-up. in adherence in pharmaceutical care,
14
Food; effect on absorption, 91-92
Food and Drug Administration, 251 -252,
785-786. 896
careers. 179, 386
policies, 148- 149
Food and Drug Modernization Act, 36
Foodborne Pathogenic Microorganisms and
Natural Toxins Handbook, 775
Formulary manager, professional opportunities,
502

Formulary systems, 362-365

drug selection, 363-364
ethical issues. 364-365
formulary maintenance, 364
history, 362-363
history of. 860-861
medication use evaluation. 364
positive. negative outcomes. 364
structure of, 363-364
Foscamet, AIDS, 442
Freedom Data Systems, software, 216, 218
Functional foods. 603-607
categorizing, 605
challenges facing. 604
examples. 603-604. 605
guidelines, 606-607
healthful foods, categories of, 604
Funding, National Institutes of Health. 576-577
Fungi images on net. 775
Furosemide, drug reaction, 27
Future directions in clinical practice in pharmacy (Hilton Head Conference),
265-266
Future of Public Health, 481

Gabapentin. 588
Gait, 586
Ganciclovir IV, AIDS, 442
Garlic. adverse reaction to, 31
Gastric emptying time, 89
Gastrointestinal, pancreatic diseases group,
Cochrane collaborative. 184
Gastrointestinal absorption, drug, 25
Gastrointestinal complaints, 588
Gastrointestinal disease, drug reactions and, 27
Gastrointestinal motility, 89
Gastrointestinal system
blood perfusion, 89-91
drug absorption in. 90-91
neurology specialty pharmacy practice, 585
Gender, adverse drug reactions and, 28
Gene therapy, 367-378
cancer; 373
cardiology, clinical trials:, 375
cystic fibrosis. 373
definition, 367-368
ethical issues. 376-377
gene therapy clinical trials, 373
monogenic disorders, 373
severe combined immunodeficiency
syndrome, 373
herpesvirus thymidine kinase, 373
HSV-TK. 373-374
infectious disease. clinical trials, 375
multidrug resistance. 376
oncology, clinical trials, 375
patient monitoring, 372-373
SCIDS. 373
vector production and administration,
371-372
vectors, 368-371
adenoviral vectors, 369-370
plasmid-based vectors, 371

Index

920
Gene therapy (cont.)
retroviral vectors, 368-369
viral transfer techniques, compared, 368
General Medical and Clinical Toxicology Guide
to Internet, 773
Generic Drug Bureau within Food and Drug
Administration, 380
Generic drugs, 97-98, 379-384
Abbreviated New Drug Application, 380
Approved Drug Products with rapeutic
Equivalence Evaluations, 380
Drug Price Competition and Patent Term
Restoration Act, 380
Generic Drug Bureau within Food and Drug
Administration, 380
legislation, 379-380
measurement, 38 1
political economy of, 382-384
regulation, 379-380
scientific basis. 380-381
Genetic disorders group, Cochrane
collaborative, 183
Genetic factors
adverse drug reactions. 29
adverse drug reactions and, 26-28
Gentamicin, pediatric pharmacokinetic data,
665
Georgetown University. health outcomes
research, 36
Georgia, pharmacy practice legislation, 272
Geriatric age-related changes
pharmacokinetic, 25
pharmacokinetics and, 25
Geriatrics
adverse drug reactions and, 25
fellowships in, 357
flu shots, effectiveness of, studies, 565
pain management. 641
Pharmacokitzetics and Drug Interactions
in Elderly and Special Issues in
Elderly African-American
Populations, 481
Germany, health care systems, 394-395
Gingival hyperplasia, caused by phenytoin, 586
Gingko biloba. adverse reaction to, 31
Ginseng, adverse reaction to, 3 1
Glatiramer acetate, 587, 588
Glaucoma, drug reactions and, 27
Glioblastoma, gene therapy trials, 374
Global planning. clinical evaluation, drugs,
135-136
Glucocorticoids, 588
Glucose 6-phosphate, drug reaction, 29
Gluteal-area intramuscular injection, 673
Goldenseal, adverse reaction to, 31
Government
clinical pharmacy careers in, 385-388
Centers for Disease Control and
Prevention, 386
Commissioned Officer Student Training
and Extern Program, 387
Department of Veterans Affairs, 385
Federal Bureau of Prisons, 387
Food and Drug Administration, 386

Indian Health Service, 386

National Institutes of Health, 386-387
U S . Armed Services, 385-386
U.S. Coast Guard, 387
U.S. Public Health Service, 386-387
infectious diseases opportunities in, 471
Government hospital
clinical pharmacy, economic analysis,
307-321
university-affiliated, economic analysis,
307-321
Government regulatory agencies, careers
options, clinical pharmacy
scientist, 179
Government-affiliated ambulatory clinic,
clinical pharmacy, economic
analysis, 307-321
Graduate, advanced professional educational
programs, 556
Graduate professional educational
programs, 556
Grants, National Institutes of Health, 578
Grapefruit juice, as cytochrome P450
inhibitor, 247
Group A streptococci, effect of
erythromycin, 60
Group practice pharmacist, professional
opportunities, 502
Growing Up Tobacco Free: Preventing Nicotine
Addiction in Children and Youths,
481, 892
Guillain barre, 587
GVP Medicare Billing, software, 216, 218
Gynecological cancers group, Cochrane
collaborative, 183

Haematological malignancies group, Cochrane

collaborative, 183
Haemophilus influenzae type b, 712
Hair loss, that could be, 586
Halcioiz: An Independent Assessment of Safe@
and EfJicacy Data, 481
Hallucinations, 585, 588
Haloperidol, 67 1
Halothane, adverse drug reaction, 29
Handbook on Injectable Drugs, American
Society of Health-System
Pharmacists, 57
Hardware array. 215-220
Harvard University, health outcomes
research, 36
Hawaii, pharmacy practice legislation, 272
HBS, Inc., software, 216, 218
HCC, software, 216, 218
Head cancer, gene therapy trials, 374
Headaches, 587, 588
Health care
evolving view of, 193- 194
financing, 401 -403
policy, careers options, clinical pharmacy
scientist, 179
Health care systems outside US., 389-396
Canada, 390

Germany, 394-395
Japan, 391-392
Mexico, 395
National Institute for Clinical Excellence,
393-394
Republic of South Africa, 390-391
United Kingdom, 392-394
Health care systems within U S . , 397-407
access to health care, 403-405
health care financing, 401 -403
organization of, 399-400
trends in, 400-401
Health maintenance organization clinic, clinical
pharmacy, economic analysis,
307-321
Health outcomes research, 35
Health Plan Employer Data and Information Set,
model clinical practices, managed
care, 510
Health Resources and Services
Administration, 253
Health services research, 408-414
access to healthcare, 41 1
clinical evaluation, 41 1-412
consumer behavior, 412
data sources, 409
definition of, 408-409
financing of healthcare, 410-41 1
health policy, relationship between, 409-410
informatics, 412
publications, 413
quality of care, 41 1
role of pharmacy profession in, 410-412
study setting, 408
subject selection, 408-409
work force, 412
Health status assessment, 415-427
advantage of, 423
Agency for Health Care Policy and
Research, 417
definitions, 41 8-419
International Quality of Life Assessment
Project, 422
measuring health, 419-422
Medical Outcomes Study, 417
outcome measures, 416-417
psychometric theory, 417-418
Rand HIE, 416-417
reliability, 418
validity, 418
Healthful foods, categories of, 604
Health-systems, clinical pharmacy careers in,
428-431
career ladders, 430
education, 429-430
range of career activities, 428-429
acute care, 428
ambulatory care: 428
community pharmacy, 428
drug information service, 428
home care services, 428
long-term care, 428
management of pharmacy services,
428-429

921

Index
Health-systems, clinical pharmacy careers in
(cont.)
therapeutic drug monitoring service, 428
sites. 430
work settings. 429
general clinical practice model. 429
outpatient pharmacy. 429
Healthy People 2010. 432-434
Heart attack, beta blocker treatment after,
effectiveness of, studies, 565
Heart disease. as cause of death, 404
Heart failure, drug reactions and, 27
Heart group, Cochrane collaborative, 183
HEDIS. See Health Plan Employer Data and
Information Set
Hematologic disease, drug reactions and, 27
Hematology: Basic Principles and Practice, 622
Hematology, home care, 442
Hematology system, neurology specialty
pharmacy practice. 585
Hematopoiesis chart. 109- 110
Hemophilia, drug reactions and, 27
Hemorrhage, with routine medical care, vs.
pharmacist-managed
anticoagulation, 65
Heparin, 587
Hepatic disease, adverse drug reactions and.
25 - 26
Hepatic system, neurology specialty pharmacy
practice, 585
Hepatitis A, 712
Hepatitis B. 712
Hepato-biliary group, Cochrane
collaborative, 183
Herbal medicines, adverse drug reactions. 3 1
Herbal therapies. adverse drug reactions and, 28
Herpes simplex, with AIDS, 442
Herpes zoster, with AIDS, 442
Herpesvirus thymidine kinase. gene
therapy. 373
High blood pressure, controlling, effectiveness
of, studies, 565
Higher education. academic clinical
pharmacy, 2
Hilton Head Conference, directions in clinical
practice in pharmacy. 265 -266
Hip fracture. gene therapy, 376
Histamine-receptor antagonist, clinical pharmacy. economic analysis, 307-321
Histoplasmosis, with AIDS, 442
History form. patient, 288
HIV, 586
Confronting AIDS: Direction f o r Public
Health, Health Care, and
Research, 48 1
No Time to Lose: Getting More from HIV
Prevention, 481
post-exposure prophylaxis. 891 -898
transmission, occupational, risk of, following
exposure, 892
universal precautions, 891 -898
unlabeled indications, drug use for, 551
HIViAIDS group, Cochrane
collaborative, 183

HIV/AIDS Treatment Information

Service, 896
Holistic medicine, 774
Home care practice, 435-438. 502
activities, 436-437
career options, 437-438
education-related issues. 437
Medicaid usage, 516
patient database, 436
preadmission criteria, 436
Spain, 439-446
advantages, 439
AIDS, 441 -443
antibiotic therapy, cost savings, 441
classification, 439-440
community-based, 440
family environment, 440
home environment, 440
hospital-based, 439-440
infections, 441
organization, 439-440
parenteral antibiotics, 441
patient selection. 440-441
type of interventions, 441
web sites. 444
work environments, 435-436
Home monitoring, 287
Hospice, 447-452
computer links, 450
documentation, from care providers, 452
Hospice Foundation of America, 450
Hospice Hands, web site, 450
managed care. clinical pharmacy
careers, 504
marketing pharmaceutical care, 45 1-452
National Hospice and Palliative Care
Organization, 450
Open Society Institute, Project Death in
America, 450
Palliative Medicine Program, 450
professional opportunities, 449
Purdue Pharma Pain and Palliative Care
Information, 450
resources. 450
Talarian map, cancer pain, 450
Hospice Foundation of America, 450
Hospice Hands, web site, 450
Hospice interdisciplinary team. 448
Hospital inpatient, Medicaid usage, 516
Hospital outpatient, Medicaid usage. 5 16
HRSA. See Health Resources and Services
Administration
HSV-TK. See Herpesvirus thymidine kinase
Human genetics research, ethical issues,
880-881
Human inmmunodeficiency virus. See HIV
Human subjects. protection of, 336
Huntingtons chorea, 585
Hydralazine, adverse drug response, 29
Hydrogenated vegetable oil, excipient in
drug, 95
Hydroxypropylmethylcellulose, excipient in
drug, 95
Hyperlipidemia, 461 -468, 585

cholesterol monitoring tests, CLIA waived

status, 466
clinic models, 463
communication, 466
community pharmacy practice, 462-463
documentation, 466
institutional pharmacy model. 464
lipid management practices, 463
lipid measurement devices, 466-467
outcomes, 813
patient education, 466
pharmacist education, 464-465
practice models, 462-464
reimbursement strategy, 467
screening programs, 462-463
Hypersensitivity reaction, to drug, 23
Hypertension, 121, 754, 812
drug reactions and, 27
nonadherence to medical care in, 18-19
Hypertension group. Cochrane
collaborative, 183
Hyperthyroidism. drug reactions and, 27
Hyperuricemia, drug reactions and, 27
Hypoalbuminemia, adverse drug reactions
and, 26
Hypothyroidism, drug reactions and, 27

ICAAC. See Interscience Conference for

Antimicrobial Agents and
Chemotherapy
ICC. See International Conference of
Chemotherapy
ICMASKO. See International Conference
on Macrolides, Azalides,
Streptogramins, and Ketolides
Idaho, pharmacy practice legislation, 272
Idiosyncratic reaction to drugs, defined, 23
IDSA. See Infectious Diseases Society
of America
Ileum, drug absorption in, 90
Imipramine, cytochrome P450, 247
Immunization practice. pharmacy-based, 56 1
documentation, 561
liability, 561
reporting. 561
Immunosuppressants, 588, 870
complications, 870
outpatient, Medicare Benefits and
Improvement Act of 2000, 530
Medicare coverage under, 530
solid organ transplant, 530
transplant facility. Medicareapproved, 530
In vitro dissolution testing, 96-97
Incontinence group. Cochrane
collaborative, 183
Independent consultant, infectious
diseases, 47 1
Indian Health Service, 252-253
careers in, 386
Indiana, regulations governing prescribing,
190
Indinavir, 895

922
Individual, vs. social interest, ethical issues.
339
Industry, drug information pharmacy practice,
291-292
Infection
Emerging Infections: Microbial Threats to
Health in United States, 481
home care pharmacy, 441
Infectious disease, 469-475, 837
board certification, 469
books, 473
contract research organization, 471
education, 469
fellowships in, 357
gene therapy clinical trials, 375
government, 47 1
guidelines, 473-474
hospital practice, 470
hospital setting, 471 -472
independent consultant, 471
industry consultantships. 475
journals. 472-473
model clinical practice settings, 471 -472
networking opportunities, 474-475
outpatient practice, 470
outpatient setting, 472
pharmaceutical industry, 470
postgraduate training, 469
professional opportunities, 470-47 1
professional societies, 474-475
training, 469
infectious Diseases Clinics of North
Anzerica, 473
Infectious diseases group, Cochrane
collaborative, 183
Infectious Diseases in Clinical Practice. 473
Infectious Diseases Society of America, 474
Inflammatory bowel disease group, Cochrane
collaborative, 183
Influenza, 7 12
Information, medical, industry-based, 525 -529
careers in, 525-529
committee involvement, 528-529
daily work flow management, 526-527
customer base, 526
documentation, 527
triage procedures, 527
volume, type of requests, 526-527
drug product information dissemination,
525-526
data on file, 526
drug information resources, 525-526
guidelines, limitations, 525
package labeling, 525-526
references, 526
education, 529
academic rotation site, 529
continuing education, 529
employee education, 529
global medical information, 528 - 529
internal support functions, 527-528
clinical research, 528
marketing, 527-528
quality assurance, 528

Index
regulatory affairs, 528
safety reporting, 528
sales, 527
labeling, promotional review committee,
528
publications committee, 528
committee involvement, 528-529
global medical information, 528-529
labeling, promotional review committee,
528
publications committee, 528
daily work flow management, 526-527
customer base, 526
documentation, 527
triage procedures, 527
volume, type of requests, 526-527
drug product information dissemination,
525-526
data on file, 526
drug information resources, 525 -526
guidelines, limitations, 525
package labeling, 525-526
references, 526
education, 529
academic rotation site, 529
continuing education, 529
employee education, 529
internal support functions, 527-528
clinical research, 528
marketing, 527-528
quality assurance, 528
regulatory affairs, 528
safety reporting, 528
sales, 527
Information technology/database manager,
professional opportunities, 502
Informed consent, 336-337, 877-878
InfoWin, 456
Inhalers, pediatric dosing, 675
Injuries group, Cochrane collaborative, 183
Innovation Associates, software. 216, 218
Institute for Safe Medication Practices, 476-477
mission, 476
objectives, 476-477
analysis-based ISMP initiatives, 476
communication-based ISMP initiatives,
477
cooperation-based ISMP initiatives, 477
education-based ISMP initiatives, 477
knowledge-based ISMP initiatives, 476
Spain, 478-479
future goals, 479
medication errors reporting program,
478-479
mission, 478
Objectives, 478
projects, 479
Institute for Safe Medication Practices-Spain,
478-479
future goals, 479
medication errors reporting program, 478 -479
mission, 478
objectives, 478
projects, 479

Institute of Medicine, 480-481

activities, 480-481
Confronting AIDS: Direction f o r Public
Health, Health Care, and
Research, 48 1
Emerging Infections: Microbial Threats to
Health in United States, 481
To Err is Human: Building Safer Health Care
System, 480
Future of Public Health, 481
Growing Up Tobacco Free: Preventing
Nicotine Addiction in Children and
Youths, 481
Halcion: A n Independent Assessment of
Safety and Eficacy Data, 481
National Academy of Sciences, chartering
by, 480
No Time to Lose: Getting More from HIV
Prevention, 481
Pharmacokinetics and Drug Interactions in
Elderly and Special Issues in
Elderly African-American
Populations, 481
Insurance companies, managed care, 292
Insurance information, patient drug history,
286
Integrative medicine, 482-486
challenges to, 484-485
clinical model, 484
Consortium of Academic Health Centers for
Integrative Medicine, 484
definition of, 483
future trends, 485
Intelligence program, Drug Enforcement
Agency, 282
Intensive care unit, clinical pharmacy, economic
analysis, 307-321
Interactions between drugs, 24-25
Interactive patient counseling, 649
Interactive Systems, software, 216, 218
Interdisciplinary team, hospice, 448
Internal medicine, fellowships in, 357
International Association for Study of Pain,
643
international Association for Study of Pain
Newsletter, 450
International Conference of Chemotherapy,
475
International Conference on Macrolides,
Azalides, Streptogramins,
and Ketolides, 475
International Conference on Retroviruses, 475
International Pharmaceutical Abstracts,
57, 487
International Quality of Life Assessment
Project, 422
International Society for Pharmacoeconomics
and Outcomes Research, 488-489
International Society of Antiinfective
Pharmacology, 474
International Technidyne Corp., 141
Internet Grateful Med, 582
Interscience Conference for Antimicrobial
Agents and Chemotherapy, 474

Index
Interviewing patient, drug history, 285-286
communication, 285
setting. 285
special patient populations, 285-286
Intestinal motility, 89
Intramuscular administration, pediatric dosing,
673-674
Intravenous administration, pediatric dosing,
666-670
Investigator, principle, clinical pharmacist as,
144- 153
American College of Clinical Pharmacy,
clinical pharmacist evaluation,
154- 160
assessment methods, 154- 159
budget, 151
current industry, 145- 148
FDA policies, 148- 149
FDA regulations, 148- 149
history, 144- 145
publication rights, 151- 152
qualifications, 152- 153
access to patients, 153
audits, 153
command of research process, 152
experience, 152
human resources, 152
local leadership, 153
local resources, 152
responsibilities of, 149- 150
template, 154, 155- 159
Investigator independence, ethical issues,
research, 340
IQOLA Project. See International Quality of
Life Assessment Project
ISAP. See International Society of Antiinfective
Pharmacology
Ischemic stroke, 587
prevention, 588
Isoniazid, 870
adverse drug response, 29
as cytochrome P450 inducer, 247
ITC Protime Microcoagulation System, 141

JAG Group, software, 216, 218

Janus Commission (American Association of
Colleges of Pharmacy), 491 -492
history, 491
members of, 492
mission, 491 -492
Japan, health care systems, 391-392
jASCorp, software, 216, 218
JCAHO. See Joint Commission for Accreditation of Healthcare Organizations
JCPP. See Joint Commission of Pharmacy
Practitioners
Jejunum, drug absorption in, 90
Johns Hopkins Center for Civilian Biodefense
Studies, 777
Johnson &Johnson, 141
Joint Commission for Accreditation of
Healthcare Organizations, 493 -495
accreditation process standards, 495

923
accreditation status, 493-495
background, 493
Joint Commission of Pharmacy Practitioners,
496-497
history, 496
member organizations, 496-497
Academy of Managed Care Pharmacy, 496
American Association of Colleges of
Pharmacy, 496
American College of Apothecaries, 496
American College of Clinical Pharmacy
(American Association of Colleges
of Pharmacy), 496
American Council on Pharmaceutical
Education, 496
American Pharmaceutical Association
(APhA), 496
American Society of Consultant
Pharmacists, 496
American Society of Health-System
Pharmacists, 496
National Association of Boards of
Pharmacy, 496
National Community Pharmacists
Association, 496
National Council of State Pharmacy
Association Executives, 496
programs, 497
Jouinal of Antimicrobial Chemotherapy, 472
Journal of Infectious Diseases, 472
Journal of Infectious Diseases
Pharmacotherapy, 473
Journal of Pain, 450
Journal of Pain and Palliative Care
Pharmacotherapy, 450
Journal of Pain and Symptom
Management, 450

Kansas, pharmacy practice legislation, 272

Karolinska Institute-Poisoning Information, 774
Kentucky
pharmacy practice legislation, 272
regulations governing prescribing, 190
Ketoconazole, as cytochrome P450
inhibitor, 247

Labeling
dietary supplements, 261 -262
package, medical information,
industry-based, 525 -526
Laboratories program, Drug Enforcement
Agency, 282
Laboratory tests, Medicaid usage, 516
Lactose, excipient in drug, 95
Ladder, career, academic clinical pharmacy, 4
Lamivudine, 895
Language bamers, drug history-taking, 286
LDL. See Low-density lipoprotein
Learning problems, Cochrane collaborative, 183
Legislation, generic drugs, 379-380
Length of hospital stay, clinical pharmacy,
economic analysis, 307 - 32 1

Leukemias, gene therapy trials, 374

Levodopa, 588
Lewy body disease, 585
Liability, manufacturer, vaccines, 559 -560
Liberty Computer, software, 216, 218
License, defined, 231
Licensure, defined, 231
Lidocaine, drug reaction, 27
Lifestream Technologies, 141, 466
Lipid management practices, 463
Lipid measurement devices, 466-467
Lipid monitoring form, 465
Lipid-lowering agents, 588
Liposome, viral transfer techniques, 368
Liquid drug products, excipients used in, 95
Literature search method, 303
Lithium, 585
Liver disease, as cause of death, 404
Liver function tests, 588
Long-term care, clinical pharmacy careers in,
498-499
consultant pharmacist services, 498
history, 498-499
job settings, 499
professional opportunities, 499
role of consultant pharmacists, 498
training, certification requirements, 499
Louisiana, pharmacy practice legislation, 272
Low plasma pseudocholinesterase, drug
reaction, 29
Low-density lipoprotein receptor, gene therapy,
375-376
Low-literacy patients, adherence with, 16
Lowy Report, Prescriptions forHealth, 791 -793
Lung cancer group. Cochrane collaborative, 183
Lupus, drug reactions and, 27
LXN Corp., 141
LXN Duet Glucose Control Monitoring
System. 141
LXN Fructosamine Test System, 141
LXN IN CHARGE Diabetes Control
System, 141
Lymphoma, gene therapy trials, 374

Magnesium stearate, excipient in drug, 95

Malignant pain, 639-640
Managed care, 506-5 11
assertiveness, 507
care, clinic coordinators, 507
case studies
all-inclusive care for elderly (PACE)
programs, 504
hospice, 504
specialty clinics, 504-505
utilization management, 504
clinical pharmacy careers in, 501 -505
case studies, 504-505
preparing for, 501-503
professional opportunities, 503 - 504
settings, 501
skills, 503
communication, mediation skills, 507
diabetes care, 258

924
Managed care (cont.)
disease management, 507-508
drug information knowledge, 507
evaluating clinical, economic data, 508-509
fellowships in. 357
health, managing, 508
innovative positions, 507
insurance companies, 292
opportunities available. 506 -509
outcomes, measuring. 509
skills, 506
strengths of pharmacy, 506
work in teams, ability to, 507
Manager of clinical initiatives, professional
opportunities, 502
iWanaging Oral Anticoagulation Therapy, Clinical and Operational Guidelines, 67
Manufacturer liability, vaccines. 559-560
Marijuana eradication program, Drug
Enforcement Agency, 282
Marketing
dietary supplements, 261 -262
input, clinical evaluation, drugs, 135
of pharmaceutical care, 451 -452
Martindale Health Science Guide-Virtual
Pharmacy Center, 774
Masked facies. 586
Matching program, resident, 841
Mayday Upper Peninsula Project, 643
McKessonHBOC, software, 216, 218
MDR. See Multidrug resistance
Measles, 712
Medicaid, 5 12-5 18
administration of drug benefit, 515
clinical pathways, 5 15
drug benefit coverage, 514-515
drug coverage, 514-516
drug evaluation, 515
extending drug coverage, 514-515
financial conundrum. 514
formulary coverage. 5 15
healthcare coverage options, 5 13-5 14
history, 5 12-5 13
individuals utilizing, 5 16
Medicare, description, 512-514
Medicare participation, 5 14
Medicare program, 5 13
original Medicare plan, 513-514
pharmaceutical care, disease management
and, 515
pharmacy benefit, tools to manage, 515
reimbursement, 516-518
resource-based relative value system,
515-516
Medical Botany Library. 775
Medical College of Wisconsin Palliative Care
Medical Program, 643
Medical communications, clinical pharmacy
careers in, 519-524
income. 519-521
training, 522-523
Medical information, industry-based, 525 -529
academic rotation site, 529
committee involvement> 528-529

Index
global medical information, 528-529
labeling, promotional review
committee, 528
publications committee, 528
daily work flow management, 526-527
customer base, 526
documentation, 527
triage procedures. 527
volume, type of requests, 526-527
drug product information dissemination,
525-526
data on file, 526
drug information resources. 525 -526
guidelines, limitations. 525
package labeling. 525-526
references, 526
education, 529
academic rotation site, 529
continuing education, 529
employee education. 529
internal support functions, 527-528
clinical research, 528
marketing, 527-528
quality assurance, 528
regulatory affairs, 528
safety reporting, 528
sales, 527
Medical NBC Online Information Server, 776
Medical outcomes study, health status
assessment, 417
Medical records. access to, 196
Medicare. 5 13
contact points, 512-514
description, 512-514
and contact points, 512-514
pharmaceutical programs, 5 12-5 18
Medicare Benefits and Improvement Act of
2000 for outpatient immunosuppressive agents, 530
Medicare coverage under, 530
solid organ transplant, 530
transplant facility. Medicare-approved, 530
Medicare+Choice, 5 14
drug step therapy, 515
Medication assistance programs, pharmaceutical
company-sponsored, 531 -532
enrollment, 531 -532
ethical issues, 532
information frequently requested, 532
internet sites, 531
medication, 532
pharmacists role. 532
Medication errors. 533-544
human reliability
curve, 539
enhancing, 539-542
manageable behaviors, 540
at-risk behavior, 540-541
high-culpability behavior, 541 -542
imperfect behavior, 540
medication-use cycle, 533-535
outcomes-measurement approach, 538 - 539
preventable patient harm, scientific
investigation, 536-539

process-improvement approach, 536-538

reporting program, Institute for Safe
Medication Practices, 478-479
role of pharmacist, 542-543
Medication Teaching Manual. American Society
of Health-System Pharmacists, 57
Medication use evaluation, 545-549
approaches to, 547-548
goals of, 546
limitations, pitfalls of. 548
priority setting, 546-547
process, 547
role of pharmacist, 546
scope, 546
tools, resources, 548
value of, 548
Medication use for unapproved indications,
550-553
liability. 552
patient safety, 550-552
reimbursement, 552
unlabeled indications, drug use for, 551
antineoplastics, 55 1
antipsychotics, 551
HIV, 551
metoclopramide, 55 1
ondansetron, 551
MEDLINE, 580-581, 582, 773
MEDLINEplus. 582
MedMARx, 889
MedNet, 774
Melanoma, gene therapy trials, 374
Menstrual disorders, Cochrane collaborative, 183
Mental health facility, clinical pharmacy,
economic analysis. 307-321
Mental health scale, 423
Mental status. 586
Mentally retarded, Medicaid usage, 5 16
Mephenytoin, cytochrome P450, 247
Mesothelioma. gene therapy trials. 374
Metabolic. endocrine disorders group, Cochrane
collaborative, 183
Metastatic cancer, gene therapy trials, 374
Methemoglobin reductase deficiency, drug
reaction, 29
Methyl propylparaben, excipient in drug, 95
Methylcellulose, excipient in drug, 95
Methylprednisolone, 587, 870
Metoclopramide, unlabeled indications, drug use
for, 551
Metopronolol. cytochrome P450, 247
Metrika, Inc.. 141
Metrika DRx HbAlc, 141
Metronidazole. adverse drug reaction, 30
Mexico, health care systems, 395
Mexilitine, 588
Michigan
pharmacy practice legislation, 272
regulations governing prescribing, 190
Microcrystalline cellulose, excipient in drug, 95
Micromedex, software, 216, 218
Midrin, 588
Millis Commission, 554-557
clinical scientists, concept of, 556

Index
Millis Commission (cont.)
credentialing. 557
graduate. advanced professional educational
programs, 556
organization, 554-557
pharmacy, defining, 555
pharmacy curricula, design of, 555-556
preparation of pharmacists. environment
for. 556
providers of drug information, pharmacists as,
554-555
Mini Mental Status Examination, 588, 741 -748
Minnesota. pharmacy practice legislation, 272
Minorities, adherence to medical care, 16- 17
Mission statement, Academy of Managed Care
Pharmacy. 6
Mississippi
pharmacy practice legislation, 272
regulations governing prescribing, 190
Mitretek Systems, 776
Model clinical practices, managed care,
509-510
Health Plan Employer Data and Information
Set. 510
Joint Commission on Accreditation of
Healthcare Organizations. 509
National Committee for Quality Assurance,
509
networking opportunities, 510
Molecules, passive diffusion of, 87
Monogenic disorders. gene therapy, 373
Montana, pharmacy practice legislation, 272
Motor function, 586
Movement disorders group. Cochrane
collaborative, 183
MTM Bioscanner 1000, 141
Multicenter. clinical pharmacy. economic
analysis, 307-321
Multidrug resistance, gene therapy. 376
Multidrug use. adverse drug reactions and, 28
Multiple sclerosis, 587. 588
Multiple sclerosis group, Cochrane
collaborative. 183
Muscle relaxants, adverse drug reaction, 29
Musculoskeletal group. Cochrane collaborative,
183
Musculoskeletal injuries group. Cochrane
collaborative, 183
Musculoskeletal system, neurology specialty
pharmacy practice. 585
Myasthenia gravis, 586, 588
drug reactions and. 27
Mycobacterium. with AIDS, 442
Myocardial ischemia, drug reactions and, 27

NABP. See National Association of Boards of

Pharmacy
NACDS. See National Association of Chain
Drug Stores
Nafcillin, 870
Nalidixic acid, adverse drug reaction. 29
Naranjo causality algorithm, adverse drug
reactions, 32

925
Narcotic analgesics, drug reaction, 27
Narrow-angle glaucoma
Cochrane collaborative, 27
drug reactions and, 27
Nasal administration, pediatric dosing, 675
National Academy of Sciences, chartering of
Institute of Medicine, 480
National Academy Press, 773
National Association of Boards of Pharmacy,
232: 270, 496
National Association of Chain Drug Stores, 232,
270
National Asthma Educator Certification Board,
American Lung Association, 232
National Cancer Institute, 621
National Certification Board for Diabetes
Educators, 232, 270
National Childhood Vaccine Injury Act of 1986,
559-563
adverse events, vaccine. 559
childhood diseases, vaccination against. 559
documentation, 561
historical advancements, 559
immunization practice, pharmacy-based, 561
liability, 561
manufacturer liability, 559-560
National Vaccine Injury Compensation
Program, 560-561
protection under NCVIA, 561
reporting, 561
Vaccine Injury Act of 1986, 560-561
vaccine injury table, 560
National Chronic Pain Outreach Association,
643
National Clinicians Postexposure Hotline, 896
National Committee for Quality Assurance,
model clinical practices, managed
care, 509
National Community Pharmacists Association,
232, 270, 496, 568-571
governance. 569
historical overview, 568-569
initiatives, 569-571
mission, 569
organizational structure. 569
National Comprehensive Cancer Network, 621
National Council of State Pharmacy Association
Executives, 496
National Council on Patient Information and
Education. 15
National Formulary, United States
Pharmacopeia, 887-889
National Foundation for Treatment of Pain, 643
National HIV/AIDS Clinicians Consultation
Center. 896
National Hospice and Palliative Care
Organization, 450
National Institute for Clinical Excellence,
393-394
National Institute for Standards in Pharmacist
Credentialing, 229, 232, 270,
572-574
activities, 573-574
exam registration process, 573

examination eligibility requirements. 573

NISPC DSM examinations. 573
organizational structure/meetings. 572 -573
National Institutes of Health, 25 1, 575 -579
campus, 576
facilities, 576
careers, 179; 386-387
centers. 576-578
clinical studies, 577
contracts, 578
events. 579
extramural research, 578
funding. 576-577
general information, 579
grants. 578
health information resources, 578-579
institutes, 576-578
mission, 577
offices, 576-578
public health. contributions to, 575-576
research and research policy. 179
scientific resources, 578
training, 577-578
National Library of Medicine, 580-583, 773
contacting, 583
databases, 582
ClinicalTrials.gov. 582
Internet Grateful Med, 582
MEDLINE, 582
MEDLINEplus, 582
PubMed, 582
PubMed Central, 582
TOXNET, 582
electronic publishing, 583
highlights of. 581
history. 580
MEDLINE. 580-581
pharmacy practice. research, 581 -582
PubMed, vs. Internet Grateful Med, 582
telemedicine, 583
National Vaccine Injury Compensation
Program. 560-561
NCBDE. See National Certification Board for
Diabetes Educators
NCCN. See National Comprehensive
Cancer Network
NCPA. See National Community
Pharmacists Association
NCPIE. See National Council on Patient
Information and Education
NCQA. See National Committee for
Quality Assurance
NCSPAE. See National Council of State
Pharmacy Association Executives
Nebraska, pharmacy practice legislation, 272
Neck cancer, gene therapy trials, 374
Nelfinavir, 895
Nephrology. fellowships in, 357
Networking opportunities
anticoagulation, 68
bone manow transplant, 110
cardiology. 123- 124
drug information pharmacy practice, 293-294
infectious diseases, 474-475

Index

926
Networking opportunities (cont.)
model clinical practices, managed care, 510
neurology specialty pharmacy practice,
589-590
specialty practice, clinical pharmacokinetics,
166-167
Neurological disorders, drug reactions and,
27
Neurological system, neurology specialty
pharmacy practice, 585
Neurology, fellowships in, 357
Neurology specialty pharmacy practice,
584-590
cardiovascular system and, 585
educational opportunities, 589 -590
EENT, 586
endocrine system and, 585
fluid/electrolyte/nutritional status, 585
gastrointestinal system, 585
guidelines used in, 589
GU/reproductive system, 585
hematology system. 585
hepatic system, 585
inpatient neurology specialty practice,
586-587
musculoskeletal system, 585
networking opportunities, 589-590
neurologic patient, approach to. 584
neurological system, 585
outpatient neurology specialty practice,
587-589
pharmacotherapy history, 584
psychological exam, 585
pulmonary system, 585
renal system, 585
review of systems, 584-586
vital signs, 585
skin. 586
targeted neurological exam, 586
vital signs, 585
Neuropathic pain, 641-642, 754
Neuropathy, 586
Neurosis, Cochrane collaborative, 183
Neutraceuticals, 603-607
categorizing, 605
challenges facing, 604
examples, 603-604, 605
guidelines, 606-607
healthful foods, categories of, 604
Nevada
pharmacy practice legislation, 272
regulations governing prescribing, 191
New business developer, professional
opportunities as, 502
New England Cochrane Center, 185
New Mexico
pharmacy practice legislation, 272
regulations governing prescribing, 191
Nicotine addiction, Growing Up Tobncco Free:
Preventing Nicotine Addiction in
Children and Youths, 481
Nifedipine, cytochrome P450, 247
NIH. See National Institutes of Health
Nimodipine, 587

NISPC. See National Institute for Standards in

Pharmacist Credentialing
Nitrates, drug reaction, 27
Nitrites, adverse drug reaction, 29
Nitrofurantoin, adverse drug reaction, 29
No Time to Lose: Getting More from H N
Prevention, 481
Nonadherence in pharmaceutical care
assessing, 12- 13
direct methods, 12
indirect methods, 12- 13
as behavioral disorder, 11
children, 17- 18
chronic diseases, 18- 19
community resources, 17
cultural differences and, 17
defined, 10- 11
Eldercare Patient Education Series, 15
elderly, 15- 16
cognitive limitations, 15
limited access to or affordability of health
care services, 15
physical impairments, 15
polyphannacy, 15
risk factors for nonadherence, 15
ethnic minorities, 16- 17
factors affecting, 13
fear tactics, 14
follow-up, 14
hypertension, 18- 19
implement reward system, 14
informed medication consumer, patient as.
14
low-literacy patients, 16
National Council on Patient Information and
Education, 15
patient goals, 14
patient-centered adherence paradigm, 11
patient-focused interventions for, designing,
13-14
payment for adherence services, 20
Pediatric Medication Text, 15
Peter Lamy Center for Drug Therapy and
Aging, 15
pharmacotherapy, enhancing adherence to,
14-18
resources for improving, 15
risk factors for, 11
scope of problem, 10- 11
self-efficacy, 14
space considerations, 20
special populations, 14- 18
type 2 diabetes, 19
Nonalignment pain, pain management,
640-64 1
Nonsteroidal anti-inflammatory drugs
adverse drug reaction, 27
clinical pharmacy, economic analysis,
307 - 32 1
Nontraditional Pharm.D, 591 -602
admission requirements for, 592-593, 594
background information, 591 -593
degree transfer mechanisms, 591
didactic instructional methods, 594-595

distance learning, 595

Doctor of Pharmacy degree programs, 591
prior learning, assessment of, 595-599
videotaped lectures, 594-595
web-based coursework, 595
Nordic Cochrane Centre, 185
North American Mycological Association, 775
North Carolina, pharmacy practice legislation,
272
North Dakota
pharmacy practice legislation, 272
regulations governing prescribing, 191
Nuremberg Code, 341
Nursing facility
diabetes care, 257-258
Medicaid usage, 516
Nutraceuticals, categories of, 604
Nutrients, adverse drug reaction, 30
Nutrition
adverse drug reactions and, 28
status, neurology specialty pharmacy practice,
585
support, home care, 443
Nutritionist Pro, software, 360-361
Nystagmus, 586

Obstetric patients, home care, 443

Occupational HIV transmission, risk of,
following exposure. 892
Octreotide, 870
Ocular disease, drug reactions and, 27
Oddis, Joseph A,, 609-610
accomplishments, 609 - 6 10
education, 609
influence on clinical pharmacy practice,
610
positions, 609
professional involvement, 609
training, 609
Office of Secretary of Health and Human
Services, 254
Ohio, pharmacy practice legislation, 272
Omeprazole, cytochrome P450, 247
Omnicell, 456
automated delivery, 456
OmniSYS, software, 216, 218
OncoLink, 643
Oncology, 61 1-626
anticancer therapy. outcomes related to, 618
chemotherapy order verification, 6 12
clinical pharmacy opportunities, 61 1-614
clinical research, 617-618
documented benefits, 618-620
drug administration policies, 613
drug handling, 612-613
drug information, 614, 617
education, 614
fellowships in, 357
gene therapy clinical trials, 375
guidelines, 620-622
home care, 442
inpatient care practice roles, 615-616
investigational drug use, 617

Index
Oncology (cont.)
medication order review, 612
model clinical practices, 614-618
outpatient care practice roles, 616-617
patient care problems, 613
patient care services, 620
patient education, 613
patient monitoring, 613-614
practice guideline development, 618-619
reimbursement, 620
resources for, 620-623
roles, 612
specialist interventions, 619-620
summary of interventions, 619
transitional patient care practice roles, 616
Ondansetron, unlabeled indications, drug use
for, 551
Open Society Institute, Project Death in
America, 450
Ophthalmic administration, pediatric dosing.
675
Opiates. 588
Opportunistic disease, with AIDS. 442
Opportunities, networking. See Networking
opportunities
OPUS Core Corporation, software, 216, 218
Oral administration, tablet, capsule, 86
Oral anticoagulants. drug reaction, 27
Oral cavity, drug absorption in, 90
Oral contraceptives, drug reaction. 27
Oral drug absorption. 88-92
blood perfusion, gastrointestinal tract, 89-91
food, effect of. 91-92
gastric emptying time, 89
gastrointestinal motility, 89
intestinal motility, 89
physiologic considerations, 88 -92
rate-limiting, 84
Orange Book. See Approved Drug PI-oducts with
rapeutic Equivalence Evaluations
Oregon
pharmacy practice legislation, 272
regulations governing prescribing, 191
Organ transplant
pharmacy practice, 869-875
solid, Medicare Benefits and Improvement
Act of 2000. 530
Organization of care group. Cochrane collaborative, 183
Organizational structure, Academy of Managed
Care Pharmacy, 6
Orphan Drug Law, 627-634
Orphan drugs, 627-634
approved, 632
current status of, 631-632
Orthostatic hypotension. 585, 588
Otic administration, pediatric dosing, 675
Outcomes, pharmaceutical. 702-706
Outcomes research. fellowships in, 357
Outcomes Research, International Society for
Pharmacoeconomics and, 488 -489
Outcomes researcher, professional opportunities. 502
Outpatient cardiology, 121 - 123

927
Outpatient pharmacist, professional
opportunities, 503
Outpatient practice, infectious diseases, 470
Ovarian cancer, gene therapy trials, 374
Oversight bodies. U.S. pharmacy, 225
Oxford Textbook of Palliative Medicine, 450
Oxidation drugs, 25

PACE programs, managed care, clinical

pharmacy careers in. 504
Package labeling, medical information,
industry-based, 525 -526
Pain: 450
Pain management. 635 -646. See also Palliative
care
acute pain services, 637-639
barriers to pain control, 636
chronic pain services, 639-641
elderly, 641
malignant pain, 639-640
neuropathic pain management, 641 -642
nonalignment pain, 640-641
nonpharmacologic measures, 637
organizations for, 642-643
pain assessment, 637
patient assistance programs, 642
types of pain, 636-637
Pain Net. 643
Palliative care, 447-452
computer links, 450
documentation, from care providers, 452
home care, 442
Hospice Foundation of America, 450
Hospice Hands, web site. 450
marketing pharmaceutical care, 45 1-452
National Hospice and Palliative Care
Organization, 450
Open Society Institute, Project Death in
America, 450
Palliative Medicine Program, 450
professional opportunities, 449
Purdue Pharma Pain and Palliative Care
Information. 450
resources, 450
Palliative Medicine Program, 450
Palsy. 586
Pancreatic diseases group, Cochrane
collaborative, 184
Paralytic poliomyelitis, 712
Parenteral nutrition, 458
Parkinsons disease. 585. 586, 588, 754
Parmacist prescribing. 718-723
evolving role of pharmacist, 718
liability, 7 19-721
policy issues, 721 -722
prescriptive authority, 718-719
Particle size, absorption and, 94
Passive diffusion. molecules, 87
Patient, physician, pharmacist, relationship
among, 331
Patient compliance. barriers to. 287
Patient data records, drug history, 284
Patient database, home care, 436

Patient drug history, 284-289

acute. chronic medical problems, 287-289
compliance, barriers to, 287
components of, 286-287
data collection forms, 289
financialhsurance information, 286
home monitoring. 287
immunizations, 287
interviewing patient, 285 -286
communication, 285
setting. 285
special patient populations, 285-286
language barriers. 286
medication allergies, 286-287
medications, 287
patient data records, 284
pharmacist-conducted, rationale, 284
social history, 287
sources of patient data, 285
caregiver/family member, 285
healthcare providers, 285
medical records. 285
patients, 285
pharmacy dispensing records, 285
types of data, 284-285
objective data, 285
subjective data. 284-285
vs. patient medical history. 284
Patient education. hyperlipidemia, 466
Patient educationkounseling, 647 - 650
communication skills, 649-650
compliance, counseling for, 650
interactive patient counseling. 649
medication counseling, 647 -650
skills, 648-649
Patient history, drug history, 284
Patient history form. 288
Patient satisfaction, 651 -655
tools to measure, 653
Patient-centered medication adherence
paradigm, 11
Patient-focused interventions for adherence in
pharmaceutical care, designing,
13-14
PDQ. See Physician Data Q u e n
PDQ-NCIs Comprehensive Cancer Database,
62 1
PDX-NHIN. software, 216, 218
PECS. See Pharmacy Electronic
Communications Standard
Pediatric Medication Text, 15
Pediatric pharmacy, 679-684
documenting benefit, 680
dosing handbooks. 681-682
journals, 682
pediatric pharmacy resources: 680-682
practice models, 679-680
professional organizations, 682-683
reference texts, 680-681
web sites, 682
websites, 683
Pediatrics. 656-678
absorption
absorptive surface area, 658

Index

928
Pediatrics (cont.)
endotracheal, 661
enzyme activity. 658
gastric emptying, 658
gastric pH, 658
intramuscular, 658 -659
intraosseous, 659
percutaneous, transdermal, 659 -660
rectal. 661
subcutaneous, 659
administration techniques, 672-673
adverse drug reactions, 26
adverse drug reactions and, 25, 26
body composition, differences in, 661 -662
central nervous system, drug penetration into.
662
density, 668
developmental physiologic changes, 657-658
disposable IV equipment, 667-668
dosage forms, 670-671
dosing regimens
drug administration, mechanical system for,
669 - 670
excipients, in medications, 664-666
extemporaneous liquid preparations, 67 1
fellowships in, 357
frequency, duration of drug administration,
669
hepatic metabolism, 662-663
historical backgroung, 656-657
inhalers, 675
intramuscular administration, 673 -674
intravenous administration, 666-670
types of, 669-670
manual administration, 669
metabolism, 662 - 663
nasal administration, 675
ophthalmic administration, 675
oral absorption, 658
oral liquids, 670-671, 672
oral medications, 670-673
oral solid dosage forms, 672-673
osmolality, 668
otic administration, 675
patient age, 660
percutaneous administration, 674
pharmacokinetics, 657-663
product selection, 671 -672
protein binding, 662
rectal administration, 674
renal elimination, 663
subcutaneous administration, 674
sustained-release preparations, 67 1-672
therapeutic drug monitoring, 663 -664
sample size, 664
serum drug concentrations, 663 -664
technical factors, 664
tissue binding, 662
transdermal drug-delivery systems, 660-661
Pentamidine, AIDS, 442
Peptic ulcer, drug reactions and, 27
Peptic ulcer disease, 754, 815
Peripheral neuropathy, 585, 588
Permeability class, bioavailability and, 100

Personal interviews, ethical issues, 878- 879

Peter Lamy Center for Drug Therapy and Aging,
15
Pew Health Professions Commission reports,
685-687
pharmacy, 686- 687
reports, 685-686
Pharmaceutical Abstracts, International,
(American Society of
Health-System Pharmacists), 487
Pharmaceutical Benefits Scheme (Australia),
subsidies, 689-690
Pharmaceutical care, 692-697
collaborative partnerships, 693
compensation, 695-696
follow-up evaluation, 694-695
as generalist practice, 693
history of landmark developments, 692
measuring outcomes, 695
patient assessment, 693-694
patient care process, 693-695
pharmaceutical care plan, 694
Pharmacists Workup of Drug Therapy,
693
philosophy of, 693
practice management system, 695
Pharmaceutical Care Spain Foundation,
698-700
Pharmaceutical company-sponsored, medication
assistance programs, 531 -532
enrollment, 531 -532
ethical issues, 532
information frequently requested, 532
internet sites, 531
medication, 532
pharmacists role, 532
Pharmaceutical outcomes: 702-706
databases for, 703-704
ethics, 704
limitations of evaluating, 703
organizations, 704- 705
performance measures, 702
resources, 704-705
textbooks, 704
web sites, 704-705
Phaimaciens Sans Frontieres, 707-709
funding, 708
goal, 707
history, 707-708
human resources. 708-709
meeting, 709
missions, 708
objectives, 707
Pharmacist, physician, patient, relationship
among, 331
Pharmacists without Borders, 707-709
Pharnzacists Workup of Drug Therapy, 693
Pharmacoeconomics, fellowships in, 357
Pharmacoeconomics and Outcomes Research,
International Society for, 488-489
Pharmacoepidemiology, fellowships in, 357
Pharmacokinetics, fellowships in, 357
Pharmacokinetics, Pharmacodynamics and Drug
Metabolism Section, American

Association of Pharmaceutical
Scientists, 166
Pharmacokinetics and Drug Interactions in
Elderly and Special Issues in
Elderly African-American
Populations, 481
Pharmacokinetics and Drug Metabolism
Section, American Society for
Clinical Pharmacology and
Therapeutics, 166- 167
Pharmacokinetics/Dynamics Practice Research
Network, American College of
Clinical Pharmacy, 166
Pharmacopeia, United States, 886-890
Phartnacotherapy: Journal of Human Pharmacology and Drug Therapy, 124-725
Pharnzacotherapy Self-Assessment Program
(American Association of Colleges
of Pharmacy), 726-727
Pharmacotherapy specialty practice, 732-735
functions, 732-733
guidelines, 728-731
qualifications, 733
supplemental information, 734
value, 733-734
Pharmacovigilance, vs. risk of treatment,
736-740
clinical development, 737-738
international organizations. 737
postmarketing environment, 738-739
regulatory environment, 736-737
risk-benefit assessment. 739
Pharmacy curricula, design of, 555-556
Pharmacy Electronic Communications
Standardmational e-Claims
Standard Initiative, 113
Pharmacy technician, defined, 23 1
Pharmacy Technician Certification Board, 232
Pharm.D. See Doctor of Pharmacy
Pharmex, software, 216, 218
PharmWeb, 775
Phenelzine, adverse drug response, 29
Phenobarbital, 870
adverse drug response, 29
pediatric pharmacokinetic data, 665
Phenothiazines, drug reaction, 27
Phenytoin, 870
adverse drug reactions, 29, 30
as cytochrome P450 inducer, 247
pediatric pharmacokinetic data, 665
Physical impairments. in elderly, adherence to
medical care and, 15
Physician Data Query, 450
Physicians
Medicaid usage, 5 16
pharmacist, patient, relationship among, 331
Physicians GenRX Drug Compendium
Program, 775
Placebo effects, 752-756
Declaration of Helsinki, 755
in diseases. 753-754
factors affecting, 754-755
misconceptions, 755
use of placebos in clinical practice, 755

Index
Plantox, 775
Plasma pseudocholinesterase, drug reaction, 29
Plasmapheresis, 587
Pneumocystis carinii. with AIDS, 442
Pneumonia
with AIDS, 442
as cause of death, 404
Point-of-care software, 220
Poison information, 757-778
American Academy of Clinical Toxicology,
761-762
American Association of Poison Control
Centers, 761
analytical toxicology, 773
Certified Regional Poison Information
Center, 762
clinical toxicology organizations, 761 -762
European Association of Poisons Centres and
Clinical Toxicologists, 762
information resources, 760-761
poison center, 760
Poisoning Information, Karolinska Institute,
774
Poisonous Plant Database, 775
Poisonous Plant Guide, 775
Poisonous Plants Web Page, Cornell
University, 775
Poliovirus, 7 12
Polymer Technology Systems, Inc., 141
Polymorphic crystals, absorption, 94-95
Polypharmacy, in elderly, 15
Polysorbates, excipient in drug, 95
Polyvinyl pyrrolidone, excipient in drug, 95
Postapproval changes, 101
Post-exposure prophylaxis, HIV, 891 -898
Antiretroviral Pregnancy Registry UCSF
On-Line information, 896
Centers for Disease Control. 896
definitions, 891
Food and Drug Administration, 896
HIV/AIDS Treatment Information Service,
896
Indinavir, 895
Lamivudine, 895
National Clinicians Postexposure Hotline,
896
National HIV/AIDS Clinicians Consultation
Center, 896
Nelfinavir, 895
post-exposure prophylaxis for HIV, 892-894
rationale for, 891-892
regimens, prophylaxis, 895
therapy, 894-896
transmission risk, 892
Zidovudine, 895
Post-marketing surveillance, 785 -790
Food and Drug Administration, 785-786
future direction of, 789
justification of need, 785
weaknesses, strengths of current system,
788-789
Potassium, drug reaction with, 30
Practice agreements, collaborative, 199-206
Practice Guidelines Initiative, 621

929
Preadmission criteria, home care, 436
Prednisolone, 870
Preparing Drug Ififormation Response, 293
Prescription drug benefit administrators,
diabetes care. 258
Prescriptions for Health: Lowy Report, 791 -793
Preventive medicine, 794-800
Primaquine, adverse drug reaction, 29
Primary care: 39-42, 801-817
degrees, 40
job activities, 39-40
long-term opportunities, 40-41
salary range, 40
site description, 41
training, 40
work settings, 39-40
Primidone, 870
Principal investigator, clinical pharmacist as,
144-153
American College of Clinical Pharmacy,
clinical pharmacist evaluation,
154- 160
assessment methods, 154- 159
budget, 151
current industqr, 145- 148
FDA policies, 148- 149
FDA regulations, 148- 149
history, 144- 145
publication rights, 151- 152
qualifications, 152- 153
access to patients, 153
audits, 153
command of research process, 152
experience, 152
human resources, 152
local leadership, 153
local resources, 152
responsibilities of, 149- 150
template, 154, 155-159
Principles and Practice of Biologic Therapy oj
Cancer, 622
Principles and Practice of Gynecologic
Oncology, 622
Principles and Practice of Infectious Diseases,
473
Principles and Practice of Supportive Oncology,
450, 622
Principles of Scientific Literature Evaluation:
Critiquing Clinical Drug Trials, 293
Privacy
ethical issues, 878-879
software, 222
Privacy legislation, 113
Privileging, defined, 231
Probenecid, adverse drug reaction, 29
Procainamide, adverse drug response, 29
Product design, 82-84
biopharmaceutic considerations in, 83
Professional associations, 8 18-821
Proficiency testing, Clinical Laboratory
Improvement Amendments of
1988, 142
Program in Evidence-Based Care and Cancer
Care Ontario, 621

Program Support Center, Department of Health

and Human Services, 254-255
Project Death in America, Open Society
Institute, 450
Propylene glycol, excipient in drug, 95
Prostate, and breast cancer, gene therapy trials,
374
Prostatic cancers group, Cochrane collaborative,
184
Protocol, clinical evaluation, drugs, 133- 134
Pseudocholinesterase, drug reaction, 29
Psychiatric pharmacy specialty practice,
822 - 826
benefits of specialty practice, 824
international, 825
model practice settings, 823-824
networking, 824
tools, 824
Psychiatry, fellowships in, 357
Psychological exam, neurology specialty
pharmacy practice, 585
Psychometric theory, health status assessment,
417-418
PTCB. See Pharmacy Technician Certification
Board
Ptosis. 586
PTS. See Polymer Technology Systems
PTS Bioscanner, 141
Publication rights, principal investigator,
clinical pharmacist as, 151- 152
Publications committee, medical information,
industry-based, 528
PubMed, 582, 773
vs. Internet Grateful Med, 582
PubMed Central, 582
Pulmonary, fellowships in, 357
Pulmonary diseases, as cause of death, 404
Pulmonary system, neurology specialty
pharmacy practice, 585
Purdue Pharma Pain and Palliative Care
Information, 450
Pyxis, 456
automated delivery, 456

QS/l Data Systems, software, 216, 218

Quality assurance
Clinical Laboratory Improvement
Amendments of 1988, 142
clinical pharmacy practice, 827-835
Quality Assurance, National Committee for,
564 - 567
2000 NCQA Board of Directors, 566
accreditation, certification programs, 565 -566
accreditation survey, 564-565
accreditation survey standards, classification
of, 565
antidepressant medication management, 565
beta blocker treatment, after heart attack, 565
breast cancer screening, 565
cervical cancer screening, 565
comprehensive diabetes care, 565
effectiveness of care measures, examples of,
565

930
Quality Assurance, National Committee for
(cont.)
flu shots, for older adults, 565
HEDIS, 565
high blood pressure, controlling, 565
NCQA contact information, 566
NCQA information, 566
NCQNHEDIS, pharmacy practice, 566
quality compass, state of managed care
quality report, 566
Quality initiatives manager, professional
opportunities. 502
Quality of healthcare, 41 1
Quinidine
adverse drug reaction, 29
as cytochrome P450 inhibitor, 247
drug reaction, 27
Quinine
adverse drug reaction, 29
drug reaction, 27

Rapid acetylator, drug reaction. 29

Rectal administration, pediatric dosing, 674
Rectum, drug absorption in, 91
Rectum disease, gene therapy, 376
Refampin. 870
Registered, defined, 23 1
Regulations governing pharmacist prescribing.
190-191
Regulatory environment, pharmacovigilance,
736-737
Reimbursement, disease management, 269-27 1
Renal disease
adverse drug reactions and. 26
cell cancer, gene therapy trials. 374
gene therapy, 376
Renal elimination, pediatric dosing, 663
Renal excretion. drugs, 25
Renal group, Cochrane collaborative, 184
Renal system, neurology specialty pharmacy
practice, 585
Reporting systems, adverse drug reactions,
28 - 32
Reproductive system, neurology specialty
pharmacy practice, 585
Reprotox, 774
Republic of South Africa, health care systems,
390-391
Rescot Systems Group, software, 216, 218
Research
health services, 408-414
access to healthcare, 41 1
clinical evaluation; 41 1-412
consumer behavior, 412
data sources. 409
definition of, 408-409
financing of healthcare, 410-41 1
health policy, relationship between,
409-410
informatics, 412
quality of care, 41 1
role of pharmacy profession in, 410-412
study setting, 408

Index
subject selection, 408-409
work force, 412
research policy, careers options, clinical
pharmacy scientist, 179
Research ethics, scientist, clinical pharmacy,
178-179
Residencies, 837- 842
accreditation. 838
evolution of, 838-840
information on, 840- 841
prerequisites for training, 840
resident matching program. 841
types of, 837-838
Residency. defined, 23 1
Resistance
pathways for. 59
variables involved in, 59
Respiratory disease, drug reactions and, 27
Respiratory infection group, Cochrane
collaborative, 183
Respiratory insufficiency. drug reactions and, 27
Retail Mgmt. Products. software, 216, 218
Retail network manager, professional
opportunities, 502
Retrovims, viral transfer techniques, 368
Reward system, in adherence in pharmaceutical
care. 14
Rheumatic disease, drug reactions and, 27
Rheumatoid arthritis, gene therapy, 376
Rheumatology, fellowships in, 357
Rhode Island, pharmacy practice legislation,
272
Rifampin, as cytochrome P450 inducer. 247
Riluzole. 588
Risk factors for nonadherence in pharmaceutical
care. 11
RMS. software, 216. 218
RNA. software. 216, 218
Robert Wood Johnson Foundation. 643
Roche Diagnostics, 141
RRIS. See FEMA Rapid Response Information
System
Rx InHand, software. 360
Rx30. software. 216: 218
RxList Internet Drug Name Category Cross
Index, 775
Rx-Net, Inc., software. 216, 218
RxWeb. software. 360

Safe Medication Practices, Institute for,

476 - 477
mission, 476
objectives, 476-477
analysis-based ISMP initiatives, 476
communication-based ISMP initiatives, 477
cooperation-based ISMP initiatives, 477
education-based ISMP initiatives, 477
knowledge-based ISMP initiatives. 476
Spain, 478-479
future goals, 479
medication errors reporting program,
478-479
mission, 478

objectives, 478
projects, 479
Salary range, clinical pharmacy careers, 40
SAMHSA. See Substance Abuse and Mental
Health Services Administration
San Francisco Cochrane Center, 185
Sarin nerve gas. 777
Satisfaction. of patient, 651 -655
tools to measure, 653
Saw palmetto, adverse reaction to, 31
Schizophrenia, 585, 754
Schizophrenia group, Cochrane collaborative,
184
SCIDS. See Severe combined
immunodeficiency syndrome
Scientific integrity, ethical issues, research,
340
Scientist, clinical pharmacy, 174- 180
behavioral development, 178
communication skills, 178
definitions of, 176
literature tracking, evaluation, 177
research ethics, 178- 179
scientific thinking, 177- 178
skill sets, 177- 179
technical proficiency. 178
training, 175-177
Scope of practice, defined, 23 1
Scottish Pharmacists in Mental Health. 825
Screening methods, adverse drug reactions, 30
ScripMaster, software. 216, 218
ScripPro, software, 216, 218
Scripworld Pharmaceutical News, 775
Search method, literature. 303
Security, software, 222
Sedation and/or confusion, agents causing, 586
Seizure disorder. 815
Seizures, 587
prophylaxis. 587
Selegiline, 588
Self-efficacy, nonadherence in pharmaceutical
care and, 14
Serum drug concentration, clinical pharmacy,
economic analysis, 307 -321
Sesame oil, excipient in drug, 95
Severe combined immunodeficiency syndrome,
gene therapy, 373
Shortage, pharmacists, Canada, 113
Siberian ginseng, adverse reaction to, 31
Side effects, drug, defined, 23
SIDP. See Society of Infectious Diseases
Pharmacists
Singapore Ministry of Health. Poison
Information Centre, 775
Sirolimus, 870
Skilled nursing facility, clinical pharmacy,
economic analysis, 307 -321
Skin, neurology specialty pharmacy practice,
586
Skin group, Cochrane collaborative, 184
Slow acetylator. drug reaction: 29
Slurred speech, 586
Smart Solutions. software, 216, 218
Smoking cessation, 588

Index
Society of Hospital Pharmacists of Australia,
851-853
Clinical Pharmacy Practice Guidelines.
170- 173
Society of Infectious Diseases Pharmacists,
474
Sodium alginate. excipient in drug, 95
Sodium carboxymethylcellulose, excipient in
drug. 95
Software. 214-222. 456
associated performance-enhancement tools,
221
clinical software attributes, 221
confidentiality, 222
documentation. 220-221
Drug Information Framework, 360
hardware array, 215-220
InfoWin, 456
Nutritionist Pro: 360-361
point-of-care software, 220
privacy, 222
recommendations. 222
Rx InHand, 360
RxWeb: 360
security, 222
Solid drug products, excipients used in. 95
Solid organ transplant, Medicare Benefits and
Improvement Act of 2000. 530
Solubility
absorption and, 93
bioavailability and, 99- 100
Sorbitol. excipient in drug, 95
Sources of patient data. 285
caregiver/family member, 285
healthcare providers. 285
medical records, 285
patients, 285
pharmacy dispensing records, 285
South African Cochrane Centre. 185
South Carolina, pharmacy practice legislation,
272
South Dakota
pharmacy practice legislation, 272
regulations governing prescribing, 191
Spain
clinical pharmacist in clinical trials, 843- 849
home care pharmacy practice, 439-446
advantages, 439
AIDS, 441-443
antibiotic therapy, cost savings, 441
classification. 439-440
community-based, 440
family environment, 440
home environment, 440
hospital-based. 439-440
infections. 441
organization, 439-440
parenteral antibiotics, 441
patient selection. 440-441
type of interventions, 441
web sites, 444
hospital pharmacy practice, 453-460
activities conducted in, 454-459
automated delivery, 456

931
central intravenous additive service.
457-458
computer software, 456
drug dispensing/distribution, 455 -457
drug information, 458
drug surveillance, 459
enteral, parenteral nutrition, 458
foreign drugs, 457
future trends, 459
history of, 453
management. 455
manufacture, 457
medical devices, activities related to, 459
pharmacoeconomics, 459
radiopharmacy, 459
research drugs. 457
stocks in wards. 457
therapeutic drug monitoring, 458-459
training program, 454
transition in. 453-454
Institute for Safe Medication Practices,
478-479
future goals, 479
medication errors reporting program,
478-479
mission. 478
objectives, 478
projects. 479
Pharmaceutical Care Spain Foundation,
698-700
policy documents. laws. clinical pharmacy
practice, 779-784
Spanish Society of Hospital Pharmacy, 854-856
directors of publications, 856
governing body, 855-856
permanent board, 856
Special populations. adherence in
pharmaceutical care, 14- 18
Specialized Information Services of National
Library of Medicine, 773
Specialty clinics, managed care, clinical
pharmacy careers in, 504-505
Specialty practice
clinical pharmacokinetics, 161- 169
American Association of Pharmaceutical
Scientists
Pharmacokinetics, Pharmacodynamics
and Drug Metabolism Section.
166
Population Pharmacokinetics and Pharmacodynamics Focus Group, 166
American College of Clinical Pharmacy.
Pharmacokinetics/Dynamics
Practice Research Network, 166
American Society for Clinical Pharmacology and Therapeutics, Pharmacokinetics and Drug Metabolism
Section, 166- 167
American Sociery of Health-System Pharmacists, Supplemental Standard and
Learning Objectives for Residency
Training, 166
benefits of, 165- 166
materials useful to, 166

model clinical practices. 164

networking opportunities. 166- 167
professional opportunities, 161- 164
pharmacotherapy, 732-735
functions, 732 -733
qualifications, 733
supplemental information, 734
value, 733-734
Spironolactone, adverse drug reaction, 30
Spontaneous reporting, in pharmaco-epidemiologic studies, 30-31
SRS, software. 216, 218
St. John's wort, adverse reaction to, 31
Stages in clinical evaluation of drugs: 130-133
"Standards 2000," American Council on
Pharmaceutical Education, 8-9
Standards in Pharmacist Credentialing, National
Institute for, 572-574
activities. 573-574
exam registration process. 573
examination eligibility requirements, 573
NISPC DSM examinations, 573
organizational structureimeetings, 572-573
Starch, excipient in drug. 95
State Pharmacy Association Executives,
National Council of, 496
State regulations governing pharmacist
prescribing. 190-191
Statement of continuing education credit,
defined, 224, 231
Stearic acid, excipient in drug, 95
Steroids. 587
Stimulants, 588
Stomach, drug absorption in, 90
Stomatitis, 586
Stool softeners, 587
Street drugs, 774
Stroke. 585, 586
as cause of death. 404
risk, 585
Stroke group. Cochrane collaborative, 184
Study volunteers. payment to, 337
Subarachnoid hemorrhage. 587
Subcutaneous administration. pediatric dosing.
674
Subfertility group, Cochrane collaborative, 183
Substance Abuse and iMental Health Services
Administration, 253-254
Succinylcholine
adverse drug reaction. 29
Sucrose. excipient in drug. 95
Sugar-containing drugs, 671
Suicide. as cause of death, 404
Sulfadimidine, 870
Sulfaphenazole, as cytochrome P450 inhibitor,
247
Sulfasalazine. adverse drug response, 29
Sulfinpyrazone, 870
Sulfonamides, adverse drug reaction, 29
Superficial solid tumors. gene therapy trials,
374
Support services, Medicaid usage, 5 16
Suremed, 456
automated delivery, 456

932

Surveillance, post-marketing. 785 -790

Food and Drug Administration, 785-786
future direction of, 789
justification of need, 785
weaknesses, strengths of current system,
788-789
Sustained-release preparations, 67 1-672
SymRx, software, 216, 218

Tablet, oral administration of, processes

following, 86
Tacrine, 588
Tacrolimus, 870
Talc, excipient in drug, 95
Tears, artificial, 587
TechRx, software, 216, 218
TEHIP. See Toxicology Environmental Health
Information Program
Telemedicine, National Library of Medicine,
583
Tenure system, academic clinical pharmacy,
changes in, 2
Tetracycline, adverse drug reactions, 30
Texas
pharmacy practice legislation, 272
regulations governing prescribing, 191
Theophylline, 93
adverse drug reaction, 27, 28
cytochrome P450, 247
pediatric pharmacokinetic data, 665
Therapeutic drug monitoring, 458-459
clinical pharmacy, economic analysis,
307-321
Therapeutic Guidelines Limited (Australia),
857-859
additional readings, 859
current initiatives, 858-859
history, 857
major directions, 859
mission, 858
objectives, 858
organizational structure, 857- 858
Therapeutic interchange, 860- 863
formulary system, history of, 860-861
guidelines, 864-868
process of, 861-862
Thiazide diuretics, drug reaction, 27
Third-party payer issues. 1 13
Throat disorders group, Cochrane collaborative,
183
Thromboembolism, with routine medical care,
vs. pharmacist-managed
anticoagulation, 65
Thrombosis, anticoagulation, 64
Thrush, 586
Thyroid disorders, 585
Ticlopidine, 587, 870
Titinium dioxide, excipient in drug, 95
TMT, software, 216, 218
To Err is Human: Building Safer Health Care
System, 480
Tobacco. See also Smoking
addiction group, Cochrane collaborative, 184

Index
as cytochrome P450 inducer, 247
Tobutamide, cytochrome P450, 247
Tolazamide, adverse drug reaction, 30
Toxic reaction to drug, defined, 23
Toxicology Environmental Health Information
Program, 774
TOXNET, 582
TOXNET ToxLine, 774
tPA, 587
Tragacanth, excipient in drug, 95
Traineeship, defined, 23 1
Training
in academic clinical pharmacy, 4
anticoagulation clinical pharmacy practice,
66-67
long-term care, clinical pharmacy careers in,
499
National Institutes of Health, 577-575
scientist, clinical pharmacy, 176
Transcylcypromide. adverse drug reaction, 30
Transition, in academic clinical pharmacy, 1-3
academicians, evolution of, 3
higher education, 2
reward system, changes in, 2
tenure system, changes in, 2
Translational research, fellowships in, 357
Transplantation, organ
facilities, Medicare-approved, 530
fellowships in, 357
Medicare Benefits and Improvement Act of
2000, 530
pharmacy practice, 869- 875
Tri-Council Policy Statement: Ethical Conduct
f o r Research Involving Humans,
876-881
Tricyclic antidepressants, 588
drug reaction, 27
Triptans, 587, 588
Twenty-first century, pharmacy in, 749-75 1
Two Point Conversions, software, 216, 218
Type 2 diabetes, nonadherence to medical care
in, 19
Tyramine, drug reaction with, 30

U.K. Cochrane Centre. 186

Unapproved indications, medication use for,
550-553
United Kingdom, health care systems, 392-394
United Kingdom Clinical Pharmacy
Association, 883-885
business management group, 883-885
care of elderly, 884
critical care group, 884
education, 884
infection management group, 885
primary care, 884
quality assurance group, 884-885
surgery, 885
United Kingdom Psychiatric Pharmacy Group,
825
United States
causes of death in, 404
health care systems within, 397-407

access to health care, 403-405

future of, 405-406
health care financing, 401-403
organization of, 399-400
trends in, 400-401
United States Pharmacopeia, 886-890
convention membership, 887
history, 886
initiatives, 889- 890
dietary supplement verification program,
889
international, 890
meetings, 890
monograph development, 889-890
priorities, 890
MedMARx. 889
mission, 886
National Formulary, 887-889
organizational structure, 887
pharmacopeial forum, 889
products, 887-889
reference standards, 889
standards development, 888
statutory recognition, 888-889
strengths, 886
Universal precautions, HIV, 891- 898
Antiretroviral Pregnancy Registry UCSF
On-Line information, 896
Centers for Disease Control, 896
definitions, 891
Food and Drug Administration, 896
HIV/AIDS Treatment Information Service,
896
indinavir, 895
lamivudine, 895
National Clinicians Postexposure Hotline,
896
National HIV/AIDS Clinicians Consultation
Center, 896
nelfinavir, 895
post-exposure prophylaxis for HIV, 892- 894
rationale for, 891 -892
regimens, prophylaxis, 895
therapy, 894-896
transmission risk, 892
Zidovudine, 895
University hospital, clinical pharmacy,
economic analysis, 307-321
University of Alabama at Birmingham, health
outcomes research, 36
University of North Carolina at Chapel Hill,
health outcomes research, 36
University of Pennsylvania, health outcomes
research, 36
University of Texas Cancer Pain Page, 643
Unlabeled indications, drug use for, 551
antineoplastics, 551
antipsychotics, 551
HIV, 551
metoclopramide, 551
ondansetron, 55 1
Upper gastrointestinal, pancreatic diseases
group, Cochrane collaborative, 184
Urinary catheter, 585

Index
Urinary tract infections, 585
Urologic cancers group, Cochrane collaborative,
I X4
U.S. Armed Serbices, careers in, 385-386
U.S. Army Medical Kesearch Institute of
infectious Diseases, 777
U.S. Army Rerearch Institute of Chemical
DeSense. 777
1J.S. Army Soldier and Chemical and Biological
Defense Command, 777
U.S. Coast Guard. careers in, 387
U.S. Public Hcalth Sct-vice, careers in, 386-387
USAMRICD. See U.S. Army Kescarch institute
of Chemical Defense
IJSAMRIID. Soe U.S. Army Medical Kesearch
Institute of Infectious Disease\
lJse evaluation, of medication
approaches to, 547-548
goals of, 546
limitation\, pitfalls of. 548
priority setting. 546- 547
process, 547
role o f pharmacist. 540
scope, 546
tools, resources, 548
valuc of, 548
u.\C <Jff\tllihiOl;~S,473
Utah. pharinacy practice legislation, 272
Utilization management, managed care, clinical
pharmacy careers in, 504
Utilization/case manager-, profe\sional
opportunities. 502

Vaccination programs, pharmacist-managed,

7 1 0- 7 I7
benefits of. 710-7! I
certificate program\. 7 10
immunization opportunities. 71 1-712
inodel ph;irinacist-inanaged practices.
712-716
networks, 7 I6
resources for vaccine information, 7 16
Vaccine In.jury Act, Childhood, 559-563
advcrse events, vaccine, 559

933
childhood diseases, vaccination against, 559
documentation. 561
historical advancements, 559
immunimtion practice, pharmacy-based, 56 1
liability. 561
manufacturer liability, 550-560
National Vaccine Injury Cornpenration
Program, 560-56 1
protection undct- NCVIA, 561
reporting, 561
Vaccine Injury Act of 1086. 560-563
vaccine injury table. 560
Valerian, adverse reaction to. 3 I
Vdproic acid. 585
pediatric pharniacokinetic data, 665
Vanderbilt IJniversity, health outcomes
reseat-ch, 36
Varicella, 712
v.r :
~ i ~ ~712
ax,
Vascular etidothelial growth factor, gene
therapy, 375
Vaioconstrictors. drug reaction, 27
Vectors, gene therapy, 368-371
adenovit-a1 vcetors, 369-370
plasmid-based vectors. 37 1
retroviral \ ectors, 368 - 360
Veegum, excipient in drug, 95
VEGF. S r r Vascular endothcli;il growth factor
Ventriculat- drainage, 587
Ventrogluteal intrainuscular in.jection, von
Ilochstetter technique, 674
Verapamil, cytochrorne 1450, 247
practice legislation. 272
Vcrtebrohasilar insufficiency. 587
Vertigo
medication induccd, 586
Viral traiisfer techniques, compared. 368
Virginia, pharmacy practice legislation, 272
Vi\ible Human Project, 774
Vision group, Cocht-me collaborative, 183
Vision statement, Academy of Managed Care
Pharmacy, 6-7
Vitamin R12 deficiency, 585
Vitamin K, drug reaction with, 30
Voice-lech, software, 216, 218

Volume expansion, 587

Von Hochstetter technique, ventrogluteal
intramuscular injection, 674

Walton. Charlcr, 899-901

Warfarin, 587
adverse drug reactions, 30
cytochrorne P450. 247
Washington
pharmacy pi-actice legislation. 272
regulations governing prescribing, 19 1
Weaver. Lawrence, 902-903
WHO Communicable Disease Surveillance and
Response, 777
Wi/liUf?7 S Hen?UlO/<Jg?, 622
Wisconsin. pharinacy practice legislation, 272
Wisconsin Cancer Pain Initiative, 643
Work force, health services research, 412
Wo1.k settings. clinical pharmacy careers,
39--40
World Iiealth Organization, 904-907
Cancer Pain Kelease, 643
Essential Drug List. 908-909
functions, 905 -907
history, 904
missions, 904-905
normative, harmonimtion functions, 905
operational activities, 005-907
communicable diseases, 905
emergency. humanitarian action, 905 -907
health rerearch, 907
iioncommunicable diseases, 905
in pharmaceutical \ector, 907
World Medical Association, Declaration of
Helsinki, 341 -342
Wounds group, Cochratie collaborative, I84
Wyoming, pharmacy practice legislation, 272

Xanthan gum, excipient i n drug, 95

X-ray, Medicaid usage, 516

Zidovudine, 895

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