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Hospital pharmacy in 1991: the year in review.

Issues and activities that dominated hospital pharmacy in 1991 are reviewed, and their relationship to political and economic trends of national and international importance is described. While rising costs, equitable reimbursement, and access to care continued to dominate the nation's health-care agenda in 1991, the growing interest in quality assurance was also noteworthy. Health-care reform will likely be a dominant issue during the current election year, and pharmacists are urged to play an active role in this restructuring process, both within their work settings and in their communities. Among the major concerns of hospital pharmacy in 1991 were the appropriate use of the new products of biotechnology, advances in computer and communications technology, and measuring and improving the quality of pharmaceutical care. Other issues highlighted in the literature included the need to articulate a mission statement concerning pharmaceutical care, the role of specialization in pharmacy practice, and the appropriate allocation of human resources. The literature of hospital pharmacy continues to provide insight into the progress of the profession and to serve as a benchmark that will gauge its future course.

Computers↗

Attitudes of Ohio hospital pharmacists toward pharmacy technicians.

A survey was conducted to determine the attitudes of Ohio pharmacists toward pharmacy technicians. A questionnaire was developed with questions about the current and future scope of technician responsibilities; training, certification and licensure; and possible displacement of pharmacist positions. The questionnaire was mailed in January 1990 to a random sample of 357 hospital pharmacists registered with the Ohio State Board of Pharmacy. There were 182 usable questionnaires returned, for a response rate of 51%. Nearly all the respondents (98.4%) employed pharmacy technicians. Of 32 functions listed in the questionnaire, 16 were performed by technicians at more than half of the responding hospitals. The functions performed by technicians varied depending on the size and location of the hospital; and the education, experience, and current position of respondents influenced their opinions on the appropriateness of having technicians perform several functions now and in the future. Most respondents agreed that all technicians should receive standardized training and education, and more than a third believed that technicians should be certified. The respondents did not believe that increased use of technicians would eliminate present pharmacist positions in their department but were neutral toward a statement that technicians would eliminate pharmacist positions in general. Ohio pharmacists' attitudes toward the expanding role of pharmacy technicians seemed in concert with the recommendations that have emerged in the profession.

Attitude of Health Personnel↗

Pharmaceutical care: pharmacy's mission for the 1990s.

The case for pharmaceutical care as pharmacy's mission for the 1990s is presented. The emergence of pharmacy as a clinical profession has given pharmacists the skills and knowledge to improve the outcomes of drug therapy. It also presents them with the responsibility for those results. Practitioners of pharmaceutical care are concerned with the effect of their services on patients' quality of life and not merely with the act of providing services. They work with other health-care professionals as equals to ensure that therapeutic goals are achieved and that drug-related illness does not occur or is quickly detected and resolved. To be accepted and implemented, pharmaceutical care must first overcome pharmacy's product- and service-oriented focus, opposition from other health-care professions and drug manufacturers, financial and logistical problems, and ignorance and inertia among pharmacists themselves. Through a united effort, pharmacy organizations, schools, and individual pharmacists can translate the need for pharmaceutical care into demands for it by patients, insurance companies, health maintenance organizations, and the government. Pharmaceutical skills and knowledge have developed to the point where pharmacists must share in responsibility for the outcomes of drug therapy.

Clinical Competence↗

[The pharmacy: a health resource].

In Guatemala, as is the case in many of the other Central American countries, the pharmacy is often the only health resource used outside the household. This paper analyzes knowledge, attitudes and practices of the personnel from seven pharmacies located in marginal-urban areas of Guatemala. It also studies their interaction with 3,277 users related to all diseases, specifically those related to diarrheal disease and its treatment. Findings revealed that the pharmacies' personnel handle diarrheal disease in an empirical way, using medicines to treat the cause of the diarrhea, instead of trying to prevent dehydration. There are limitations and deficiencies of knowledge and practices related to the use and abuse of non-indicative medicines, insofar as the pharmacies' personnel and users are concerned. Findings also revealed that the Oral Rehydration Salts (ORS) are not used, and prepared oral serum is used in very small amounts, because these do not fit in popular expectations of a medicine that reduces diarrheic evacuations.

Diarrhea↗

Controlling cephalosporin and aminoglycoside costs through pharmacy and therapeutics committee restrictions.

The cost-reducing effect of antibiotic restrictions imposed by a pharmacy and therapeutics (P & T) committee was evaluated. The pharmacy department developed guidelines restricting the use of second-generation cephalosporins and aminoglycosides in cooperation with the infectious disease division. The P & T committee approved the restrictions, and the pharmacy department disseminated information on the program to the hospital's physicians. Specific indications were developed for the use of amikacin, tobramycin, cefoxitin, and cefamandole. In order to prescribe a restricted antibiotic, physicians are required to write an approved indication on the physician's order form. Residents cannot prescribe restricted antibiotics for unapproved indications unless they acquire the signature of an attending physician. Pharmacy personnel closely monitor the restricted antibiotic use and enforce the established guidelines. The major impact of the restrictions was the reversal of a previous trend toward the use of more expensive second-generation cephalosporins and tobramycin to the use of first-generation cephalosporins and gentamicin. Injectable antibiotic expenses decreased by $193,172 in the first 12 months of the program. Antibiotic restrictions imposed by the P & T committee were effective in reducing the cost of antimicrobial therapy.

Aminoglycosides↗

Establishment and operation of an oncology satellite pharmacy.

The justification, establishment, and operation of an oncology satellite pharmacy in a 545-bed university teaching hospital are described. The oncology satellite pharmacy was established because of concerns expressed by nurses about the potential health hazards of handling cytotoxic drug products. The satellite pharmacy, which is located near the three floors that serve the majority of the adult and pediatric oncology inpatients, is responsible for preparing all injectable cytotoxic drug products used in the institution; this includes inpatient and outpatient use. The satellite is staffed by one full-time equivalent (FTE) supervisor, two FTE staff pharmacists, and 1.4 FTE technicians. It is open nine hours a day during the week and four hours a day on weekends. Pharmacists working in the satellite prepare all cytotoxic drug products in a laminar-flow biological safety cabinet. The pharmacists also provide clinical services for oncology patients, such as monitoring drug therapy and providing drug information to patients, nurses, and physicians. The implementation of an oncology satellite has allowed this pharmacy department to expand its services and decrease the potential risks to personnel involved in preparing and administering cytotoxic drug products.

Antineoplastic Agents↗

Six-month hospital-pharmacy-based technician training program.

A six-month training program for hospital pharmacy technicians is described. The development of this program was stimulated by the need to use departmental resources more efficiently and the desire of local hospital pharmacy directors to have trained technicians. Financial support was sought and received from the local Private Industry Council. The department selects 10 students and two alternates for each class on the basis of test performance and an interview. The program consists of 1014 scheduled hours of instruction. The first week is spent orienting the students to the program and general hospital pharmacy concepts. The next six weeks are spent in a laboratory where the students acquire their basic skills. The rest of the program, approximately 4.5 months, is spent in on-the-job training, additional didactic lectures, and field trips. The students are evaluated routinely throughout the program. At the end of the program, each participant is granted a certificate. Attrition has been low; three classes have completed the program, and 28 technicians have graduated. Twenty-five of these technicians are now employed full-time. Positive feedback has been received from the technicians' employers. This program meets the need of area hospital pharmacies to recruit trained technicians.

Curriculum↗

Positions held by graduates of ASHP-accredited pharmacy residency programs.

Current positions of graduates of ASHP-accredited residency programs were determined in an April 1983 survey of the directors of 154 ASHP-accredited residency programs. For each residency graduate (RG), respondents indicated one of 16 employment categories. Data were grouped according to number of years since completion of the residency. Responses were received from 122 directors (79%), representing 2522 RGs. The percentage of RGs in pharmacy directorships increased from 4% one to two years after graduation to 27% after 10 years. After 10 years, 49% were employed in institutional pharmacy practice and 80% in some health-related activity. Most RGs currently practice in institutional pharmacy settings or hold positions in other fields that enable them to build on their institutional pharmacy background.

Education, Pharmacy, Graduate↗

Program to disseminate information on new hospital pharmacy practices.

A five-year program to stimulate interest in contemporary pharmacy practices and disseminate information to pharmacists and other health professionals in community hospitals throughout the State of Maine is described. Pharmacists from the New England Medical Center in Boston and the Maine Medical Center in Portland conducted a program from 1973 to 1978 that included consultative services, drug information, and continuing-education components. Pharmacy consultants visited about 50% of the hospitals in the state and met with the director of pharmacy, administrator, and director of nursing who received written reports of all findings and suggestions. Most frequently, hospitals requested recommendations on drug-distribution systems, design and use of medical profiles, and design of physician order forms. Surveys at the beginning and at the end of the program indicated that the number of hospitals with unit dose systems and i.v. admixture programs increased during the life of the program; pharmacy staffing levels also increased. The program successfully brought consultative services, drug information, and educational programs to pharmacists and other health professionals in community hospitals in Maine.

Boston↗

Qualifications required in advertisements for hospital pharmacy management positions.

Advertisements for pharmacy management positions were analyzed to determine the extent to which advanced degrees or experience were required. Advertisements were collected from three professional journals for 1971-1981 for the following positions: director and assistant director of pharmacy services, director and assistant director of clinical services, director and assistant director of drug information, and clinical coordinator. The following information was obtained from each advertisement: position title, educational degree required or preferred, number of beds in institution, type of ownership of institution, residency required or preferred, and experience required or preferred. Of 224 advertisements analyzed, 124 were for directors of pharmacy, 59 for assistant directors of pharmacy, and 41 for clinical management positions. No degree was required or preferred in 85 of the advertisements. A degree qualification was specified for all the clinical management positions; 37 out of 41 required a Pharm.D. or advanced degree. Advertisements for directors and assistant directors requiring and advanced degree were evenly divided between Pharm.D. and M.S. degrees. Since 1979, the number of advertisements not specifying a degree appears to have decreased and the number specifying M.S. or Pharm.D. to have increased. Managerial experience was mentioned in 51 of 183 advertisements for directors and assistant directors. For clinical management positions, only 6 specified managerial experience and 22 required clinical experience. Many employers specified residencies as qualifications. Advanced degrees are increasingly in demand for management positions. Advancement opportunities in the future may not be as promising as in the past for pharmacists who hold only B.S. degrees.

Administrative Personnel↗

Job satisfaction of hospital pharmacy technicians in North Carolina.

Factors related to job satisfaction among pharmacy technicians in North Carolina hospitals were studied. To gather data on job satisfaction, job function, and work attitudes, a questionnaire was designed and sent to pharmacy directors and technicians at 83 North Carolina hospitals. The 389 responses represented response rates of 70.3% for technicians and 91.6% for directors. Pharmacy technicians had significantly lower job satisfaction scores (p = 0.05) for work pay, promotion, and coworkers than those reported elsewhere for other workers. There was no difference between technicians and other workers in satisfaction with supervisors. Pharmacy technicians were most satisfied with their supervisors and coworkers, least satisfied with their pay and promotion outlook, and neutral about their work. Higher satisfaction scores were found for technicians who (1) worked in smaller hospitals, (2) performed a wider variety of tasks, or (3) were over 35 years old. Directors judged technician attitudes toward their work to be slightly higher than the technicians did. The study indicates that, in addition to monetary reward, careful consideration of nonmonetary rewards and job functions could contribute to greater technician job satisfaction.

Administrative Personnel↗

Pharmacy inspections: constitutional without a warrant?

The implications of the 1978 U.S. Supreme Court decision in Marshall vs. Barlow's, Inc., regarding warrantless inspections of pharmacies are discussed. Reviewed are the Fourth Amendment to the U.S. Constitution, related U.S. Supreme Court decisions (Camera vs. Municipal Court and See vs. City of Seattle), new "probable cause" standards, and exceptions to the requirement of warrants for inspections. The effect of the Barlow's case with specific reference to FDA, DEA and state board of pharmacy inspections is discussed. Although the Barlow's case has provided further case law in the area of administrative inspections, each case still requires individual resolution. DEA inspections are well delineated by statute and regulation. Under the "licensing exceptions," warrantless pharmacy inspections by the FDA and by boards of pharmacy are probably permissible.

Government Agencies↗

The financial impact of OBRA-90 on community pharmacies: an overview.

The Omnibus Budget Reconciliation Act of 1990 (OBRA-90) may be the most significant piece of legislation affecting the practice of pharmacy since the Durham-Humphrey amendments to the Food, Drug and Cosmetic Act. As part of the OBRA-90 legislation, the Health Care Financing Administration (HCFA) was required to publish estimates of the impact of the act on states, Medicaid recipients, and pharmacies. Numerous stakeholders and researchers have commented on the HCFA estimates. We have summarized the estimates available in comments and studies and conducted a sensitivity analysis on these estimates. Our results demonstrate considerable variation in the factors important in estimating the impact of OBRA-90 on pharmacy operations. This variation indicates the scarcity of empirical data needed to produce reliable impact estimates. Demonstration projects are needed to scientifically evaluate the total impact of OBRA-90 on pharmacy practice. Moreover, further investigation of the impact of the legislation on program recipients and states is warranted.

Computers↗

Linking laboratory and pharmacy: opportunities for reducing errors and improving care.

A myriad of errors and lost improvement opportunities result from failure of clinical laboratory and pharmacy information systems to effectively communicate. Pharmacotherapy could benefit from enhanced laboratory-pharmacy linkage with respect to (1) drug choice (laboratory-based indications and contraindications), (2) drug dosing (renal or hepatic, blood level-guided adjustments), (3) laboratory monitoring (laboratory signals of toxicity, baseline and ongoing monitoring), (4) laboratory result interpretation (drug interfering with test), and (5) broader quality improvement (surveillance for unrecognized toxicity, monitoring clinician response delays). Linkages can be retrospective or real-time. Many organizations could benefit now by linking existing pharmacy and laboratory data. Greater improvement is possible through implementation of electronic order entry with real-time decision support incorporating linked laboratory and pharmacy data. While many guidelines, admonitions, and rules exist regarding drugs and the laboratory, substantial new knowledge and evidence in this area are needed. Focusing on these unmet needs and accompanying logistical challenges is a priority.

Clinical Laboratory Information Systems↗

Information on drug use in the elderly: a comparison of pharmacy, general-practitioner and patient data.

Management of pharmacotherapy by the pharmacist and the general practitioner can be a difficult task in elderly patients in whom there is a high concomitant, long-term drug use. Adequate information on drug use is essential in managing pharmacotherapy as well as in an accurate assessment of drug exposure in pharmacoepidemiologic studies. In this study data from computerized pharmacy records, general-practitioner registries and home interviews with 100 elderly patients were compared. Pharmacy records contained 80% of all the prescriptions found at the home interviews, while in general-practitioner data 40% could be traced. Use of drugs dispensed long ago reduced the validity of pharmacy and general-practitioner data. Data on analgesics (70% was found) and respiratory drugs (68%) were less traceable compared to cardiovascular (83%) and psychotropic drugs (81%). Automated pharmacy records are an important source of longitudinal data on drug use and will improve the assessment of drug exposure in pharmacoepidemiologic studies and optimize pharmaceutical care.

Aged↗

Prevalence of drug-treated diabetes mellitus in Belgium. Results of a study with the collaboration of a network of pharmacies.

Within the framework of a European concerted action on diabetes mellitus (EURODIAB SubArea C), an epidemiological study was established in Belgium in 1990 in order to estimate the prevalence of drug-treated diabetes mellitus. An assessment was made of the sales of insulin and oral antidiabetic drugs and the average daily dose used. A sample of people with diabetes, clients of 107 pharmacies, provided the data to establish average daily doses. Those pharmacies, spread over the 9 provinces of the country, represent 2% of all private pharmacies in Belgium. Over a 2 month period each pharmacist presented a questionnaire to each client receiving an antidiabetic drug. In 1990, 164 per 10,000 inhabitants were treated with antidiabetic drugs, which means that there were approximately 163,000 drug-treated diabetics in Belgium. At the time of the survey 65% of the diabetics in the sample were 60 years or older. Overall, 38% of drug-treated diabetics took insulin, and 30% of them took only human insulin. Treatment type varied by the province where the pharmacy was located. The provinces of Hainaut and Luxembourg-Namur had a higher percentage of diabetics on oral treatment. This is the first description in Belgium of the prevalence of drug-treated diabetes and of the pattern of prescribing of these drugs.

Adolescent↗

"Doi moi" and private pharmacies: a case study on dispensing and financial issues in Hanoi, Vietnam.

Vietnam, a developing country, has had comparatively good health and human survival at low cost. The economic reform changed the health care system, and private pharmacies during the last 5 years have taken over a majority of the drug distribution. Problems include weaknesses in drug regulation and reported increases in antibiotic resistance. This case study, a purposive sample of two private pharmacies in Hanoi, explored management, including dispensing, inventory and financing, using the concept of triangulation. Observations and interviews of customers were complemented by stock inventory and interviews of the pharmacy staff. Drugs were classified according to the ATC code and the essential drug list of Vietnam. Pretested protocols were used. In all 1833 encounters were studied during the 2 weeks, out of which 286 were children. Less than 1% of customers came with prescriptions and 94.9% decided by themselves which drugs to buy. Antibiotics represented 17%, of which 90% were broad spectrum. Ampicillin dominated, both in children and adults. Some 50% of the antibiotics were given for 2.5 days or less. Less than 50% of the drugs were essential drugs (ED) on dispensing and even less on inventory. Antibiotics and vitamins were the most commonly sold drugs and, overall, brand names dominated. Little if any drug information was observed. Antibiotics were said to represent the most profitable drugs, according to the pharmacy staff. More than 20% of all products were combination drugs, including irrational and popular products with antibiotics and corticosteroids and combinations of aspirin, phenacetin and caffeine. This study shows an unexpectedly high proportion of customers, being "Tu Lam Bac Sy" (their own doctors), deciding themselves which drugs to buy. Although the "Doi moi" renovation has led to much improved drug availability, at least in urban setting, our case study highlights major problems in need of urgent actions. In particular the prevailing practices regarding antibiotics and combination drugs need to be seriously scrutinized and drug regulatory mechanisms should be enforced.

Adolescent↗

["Do you have a remedy for macular degeneration?" A field study about the advice given on dietary supplementation in 60 German pharmacies].

PURPOSE: Since completion of the AREDS study, evidence has accumulated to suggest that some form of dietary supplementation may be of value in special individuals who are at risk of progressive age-related macular degeneration (ARMD). We wanted to find out which of the many supplements available are recommended in practice and which instructions, promises, and purchasing arguments are used by German pharmacies. METHODS: A blinded consultation following a standardized protocol was carried out in 60 pharmacies. RESULTS: In 36 pharmacies specific products for dietary supplementation were recommended, but the dosage never complied with the AREDS study, and in 24 pharmacies, the necessity for a medical examination or consultation with an ophthalmologist was not mentioned. Possible interactions with other drugs or side effects were generally excluded. CONCLUSIONS: Potential risks of supplement intake were underestimated. Medical knowledge of the most frequent cause of blindness in the Western world was insufficient. A clear policy of recommendations according to evidence-based criteria is needed.

Attitude of Health Personnel↗