Class of 2009 Abstract / OBJECTIVES: The purpose of this study is to describe clinical pharmacist services in a nurse practitioner (NP) run clinic and how clinical pharmacists might influence prescribing. METHODS: The description of the clinical pharmacist services is based on a 12-week experience of a clinical pharmacist and senior student pharmacist working with the nurse practitioner and nurse practitioner students. A questionaire was developed and consisted of items relating to the nurse practitioners ability to identify possible interactions of OTC medications, herbals and prescription medications. In addition, the questionnare assessed the comfort level of NP’s taking a prescription medication history, checking a patient’s prescription formulary, and selecting appropriate medication therapies. The questionaire uses a retrospective pretest format and was tested as a method of collecting data on how a pharmacist influenced NP prescribing. The site selected for this study was the Arizona State University Center for Healthcare Innovation (ASU Center) located in the heart of Downtown Phoenix (3rd Ave and Van Buren). RESULTS: Only one nurse practitioner worked at the ASU Center. The facility is new to the neighborhood and does not see many patients. The nurse practitioner partner in this project responded that working with a clinical pharmacist on a regular basis, with more patients would definitely help her hone skills necessary to identify interactions and prescribe according to a patients formulary. CONCLUSIONS: Pharmacists provide value-added services in an ambulatory care clinic run by nurse practitioners and provide valuable education and consultation on drug interactions. Pharmacist influence can be measured successfully to using a questionnaire in a retrospective pretest-posttest study design.

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Background: Drugs are one of the cornerstones in the management of many diseases. In general, drugs are used for diagnosis, prevention, mitigation of symptoms, and, sometimes, to cure disease. However, drug treatment in elderly people, especially those with dementia and cognitive impairments, may involve significant risk of adverse drug events.  The aim of this thesis was to identify the extent of potentially inappropriate drug treatment among people with dementia and cognitive impairment and to assess the occurrence and character of drug-related problems that lead to acute hospital admissions. Another aim was to assess the potential impact of a comprehensive medication review conducted by clinical pharmacists as part of a health care team on quality of patients’ drug therapy and drug-related hospital readmission rates. Method: Long-term use of antipsychotic/psychotropic drugs and associated factors were investigated among 344 and 278 people respectively with dementia living in specialized care units. Trends in the prescribing of potentially inappropriate drugs between 2007 and 2013, comprising 2772 and 1902 people, living in nursing homes in the county of Västerbotten, were assessed using six national quality indicators. Data on drug use, function in the activities of daily living, cognitive function and behavioral and psychological symptoms were collected using the Multi-Dimensional Dementia Assessment Scale. Further, an investigation of a separate corresponding population from 2012 was done, where potentially inappropriate drug use was measured before and after a total of 895 medication reviews. Finally, a randomized, controlled trial was carried out among people 65 years or older with dementia or cognitive impairment in internal medicine and orthopedic wards at two hospitals in northern Sweden. The proportion of hospital admissions that were drug-related were estimated, and also whether comprehensive medication reviews conducted by clinical pharmacists as part of a health care team could affect the risk of drug-related hospital readmissions. Results: Antipsychotic and other psychotropic drugs were frequently prescribed to people with dementia living in specialized care units for prolonged periods. Associations were found between behavioral and psychological symptoms and different psychotropic drugs. The extent of potentially inappropriate drug use declined between 2007 and 2013. In the separate corresponding population from 2012, the frequency of potentially inappropriate drug use was significantly reduced among people who underwent medication reviews. Hospitalizations due to drug-related problems among old people with dementia or cognitive impairment were prevalent. We found that inclusion of a clinical pharmacist in the health care team significantly reduced the risk of drug-related 30-day and 180-day readmissions. However, in a subset of patients with concomitant heart failure no effect was seen. Conclusion: Among patients with dementia or cognitive impairment long-term treatment with antipsychotic and other psychotropic drugs is common. The results indicate that these drugs are prescribed to treat behavioral and psychological symptoms among cognitively impaired individuals, despite limited evidence of their efficacy and the high risk of adverse effects. Drug-related problems, such as adverse drug reactions, constituted a major cause of hospital admissions. By reducing potentially inappropriate drug use and optimizing overall drug therapy, inclusion of clinical pharmacists in a health care team might improve the quality of patient care and reduce the risk of hospital readmissions among people with dementia.

The Patient Protection and Affordable Care Act (PPACA) represents one of the most significant pieces of legislation in the history of United States healthcare. The PPACA has two main goals: to increase the insured patient population in the US and to reduce the overall cost while improving the quality of healthcare in the US. To accomplish the latter goal, healthcare providers are experiencing a movement toward integrated, team-oriented models that place increasing accountability on the providers and institutions. At the same time, these integrative models emphasize effective preventive care, which is critical in reducing the country’s overall healthcare costs. As more health care institutions and providers across the country adopt the healthcare reform models of the Patient-Centered Medical Homes (PCMH) and Accountable Care Organizations (ACOs) directly under the PPACA, the demand for pharmacists is increasing. In addition, the role of the pharmacist through Medication Therapy Management (MTM) is growing as more public and private sectors adopt MTM and its standards are being used as the medication-related cornerstone for the ACOs. There is a call for lower costs and higher quality outcomes in healthcare, and the pharmacists are increasingly integrated into direct patient care and medication management. The newly integrated responsibilities of the pharmacist are numerous and almost limitless. The roleof pharmacists is expanding, and as many studies suggest, their contributions produce auspicious results.

Introduction: The complexity of the processes and the medical conditions of patients increase the probability of errors and makes patient safety a critical process in intensive care units (ICU). Although knowledge about the activities carried out by pharmacists in intensive care has increased in recent years, there is a lack of systematic reviews on the topic. Thus, the aim of this study is to show the impact of clinical pharmacy services in adult ICUs. Methods / Study Design: A systematic review was conducted, recorded in PROSPERO with nº CRD42015019592. Quasi-experimental intervention studies, cohort, case-control and clinical trials were included. The selection of studies was conducted in COCHRANE, Scient Direct, LILACS, PubMed, Scopus and Web of Science databases, published from January 2000 to May 2015. Results and Discussion: We identified 1589 studies, which after the selection process resulted in 24 studies included in the review. The main services developed were identification of adverse drug events and drug-related problem (9), educational activities (4), management of therapies/specific patients (3) management of patients on mechanical ventilation (3) development and implementation of assistance protocol (4) and interventions to reduce drug consumption and costs in the ICU (1) It was observed a reduction in the prescription errors (190.5 vs 62.5 per 1000 patients/day), the percentage of appropriate use of stress ulcer prophylaxis (14.4 vs. 6.0, p <0.001), better control glucose (211 vs 168 mg / dL, p = 0.03), reduction of days on mechanical ventilation (338.4 vs. 178.1, p = 0.004), the better dose adjustment for patients on renal replacement therapy, reduced costs and better drugs management practices. Conclusions: The clinical pharmacy services have a positive impact on clinical and economic outcomes's adult ICU patients. However, there was no impact of these services on the length of stay in ICU, length of hospital stay and mortality rates. / Introdução: A complexidade dos processos e as condições médicas dos pacientes aumentam a probabilidade de erros e torna a segurança do paciente um processo crítico nas unidades de terapia intensiva (UTI). Embora o conhecimento sobre as atividades realizadas por farmacêuticos em cuidados intensivos tenha aumentado nos últimos anos, há uma carência de revisões sistemáticas sobre o tema. Dessa forma, o objetivo deste estudo é mostrar o impacto dos serviços de farmácia clínica em UTI’s adulto. Métodos/ Desenho do estudo: Foi realizada uma revisão sistemática, registrada no PROSPERO com nº CRD42015019592. Foram incluídos estudos de intervenção quase-experimentais, coorte, caso-controle e ensaios clínicos. A seleção dos estudos foi realizada nas bases de dados COCHRANE, Scient Direct, LILACS, PubMed, SCOPUS, Web of Science, publicados de janeiro de 2000 a maio de 2015. Resultados e Discussão: Foram identificados 1589 estudos, que após o processo de seleção resultaram em 24 estudos incluídos na revisão. Os principais serviços desenvolvidos foram identificação de eventos adversos a medicamentos e PRM’s (9), atividades educacionais (4), manejo de terapias/pacientes específicos (3), manejo de pacientes em ventilação mecânica (3), desenvolvimento e implantação de protocolo de assistenciais (4) e intervenções para redução do consumo e custos com medicamentos na UTI (1). Foi observado uma redução nos erros de prescrição (190,5 vs 62,5 por 1000 pacientes/dia), no percentual de uso apropriado de profilaxia de úlcera por stress (14,4 vs 6,0, p<0,001), melhor controle glicêmico (211 vc 168 mg/dl, p=0,03), redução dos dias em ventilação mecânica (338,4 vs 178,1, p=0,004), melhor ajuste de dose em pacientes em terapia de substituição renal, redução de custos e melhores práticas de administração de medicamentos. Conclusões: Os serviços farmacêuticos clínicos têm um impacto positivo nos desfechos clínicos e econômicos de pacientes de UTI’s adulto. Contudo, não foi observado impacto desses serviços sobre o tempo de internação na UTI, tempo de internação hospitalar e nas taxas mortalidade.