Pharmacy Leadership, Touching all the Bases

Transcription

1 Pharmacy Leadership, Touching all the Bases John Fanikos, R.Ph., M.B.A. Executive Director of Pharmacy Brigham and Women s Hospital November 16 th, 2018 Abu Dhabi, UAE

2 Objectives Review important characteristics for pharmacy practice that generate leadership skills. Identify opportunities in daily practice to apply these skills.

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4 Real Estate Dietary Biomedical Laboratories Nurses Finance Materials Patient Physicians Pharmacy Information Systems

5 Outline Academic Role Education, Mentoring Guideline development Critical pathways Order sets Business Role Value and Efficiency Pharmacoeconomics Pharmacovigilence Patient Research Role Study development Drug Procurement Patient identification Drug Safety Clinical Role Appropriate drug & dose selection Patient engagement Therapy monitoring Guideline develpment

6 Case SA is a 23 YOF foreign pharmacy student. Arrives in the Boston, Massachusetts, USA for 6 months of Pharmacy training, Files application ($95) with Board of Pharmacy for Pharmacy Internship license. Completes 1,500 hours of hospital based activities: Inpatient & Outpatient operations, clinical rounds in Internal Medicine, Cardiology, Infectious Disease, Cardio- Thoracic surgery. SA s request for recognition of her training hours is unanswered by the Board of Pharmacy. SA returns to her home country.

7 Regulatory Code Violation 2015 Employed an Unlicensed Pharmacy Intern Student was not from an approved College or University of Pharmacy Has ignored rules for many years

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9 Clinical Role

10 Patient Preference 2016 ESC Guidelines for Atrial Fibrillation. Eu Heart J 2016;37:

11 Med-to-Beds Question Where is the program? Who alerts the program to patients? How is information relayed to the pharmacy? Who fills the prescriptions? How are the RXs relayed to the pharmacy for filling? Who will deliver the prescriptions to patients? How will patients be counseled? Answer The inpatient medical unit. The admitting nurse informs patients of the program and offers enrollment. IT software links the hospital and pharmacy computer system. Outpatient pharmacy fills the prescriptions. Prescriptions are either e- scripts or hard copies faxed to the pharmacy. RPhs, students and interns deliver prescriptions. RPh, students and interns provide patient counseling. 11

12 Simplifying Complex Prescription Regimens 7 Medications taken once, twice, three times daily. 30% patients dose 7 or more. 15% organized into 4 or fewer. Wolf MS. Arch Intern Med 2011;171:

13 Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL CVD) ACS or CHF patients Med Errors (N=851) IRR (95% CI) P-value 0.92 ( ) 0.32 Intervention Counseling Usual Care ADEs (N=851) 1.09 ( ) Med reconciliation 2. Med counseling 3. Adherence aids 4. Telephone follow-up call after discharge Potential ADEs (N=851) 0.79 ( ) 0.06 Medication errors, Adverse drug events Favors intervention IRR 1.0 Favors usual care IRR=incidence rate ratios; ADE=adverse drug event Kripalani S, et al. Ann Intern Med. 2012;157:1-10.

14 Hospital Utilization Re Engineered Discharge (Project RED) Usual Care (N=376) Discharge Hospital Admission RN Advocate for Appointments (N=373) Discharge RPh call for med review 2-4 days 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% P= % 31.4% P= % 16.5% 20.7% 14.9% ED Visits, Hospitalizations Usual Care Intervention Jack BW, et al. Ann Intern Med. 2009;158:

15 Outline Academic Role Education, Mentoring Guideline development Critical pathways Order sets Business Role Value and Efficiency Pharmacoeconomics Inovation Patient Research Role Methodology Project follow up Patient identification Drug Safety Clinical Role Appropriate drug & dose selection Patient engagement Therapy monitoring Guideline develpment

16 Research Role Plan-Do-Study-Act Cycle Scientific Method

17 Outcomes/Adherence Adherence Study LMWH Daily N=125 UFH BID N=28 UFH TID N=97 Number of scheduled doses Number of doses omitted P Value Adherence 94.9% 86.8% 87.8% <.001 Number of patients that received 100% of doses 77.6% 53.6% 45.4% < Number Reasons for Omitted Doses Fanikos J et al. Am J Med. 2010; 123: Refuse Off Floor MD Hold To Surgery mbulating D/C Epidural Other

18 Patient Education Program Admit to Hospital (n=583) Rx for VTE Prophylaxis RPH educational intervention Medication adherence = Administered Doses Scheduled Doses Educational Script 1. What is VTE? 2. What does the medication do? 3. Why is it important to take every dose? 4. Questions and Contact. Results and Patient Response Piazza GP. Am J Med 2012;125,

19 Emerging Tools to Improve Adherence Med emonitor Spencer Pill Boxes Med packaging epill Pillsy Pillo Smart Phone APPs 19

20 Medication Errors Top 10 Drugs Involved in Patient Harm 1. Insulin 6. Furosemide 2. Morphine 7. Vancomycin 3. Heparin 8. Hydromorphone 4. Warfarin 9. Meperidine 5. Potassium 10. Diltiazem Potential solution UFH Errors Occur Frequently 66.2% of anticoagulant related errors 1.27 errors per 1,000 patients treated with UFH 26.9 % from wrong rate or frequency 23.1 % infusion pump or parenteral delivery problems Summary of information submitted to MEDMARX SM Copyright 2002 The United States Pharmacopoeia Convention Inc. All rights reserved. 6.2% required intervention

21 Heparin Induced Thrombocytopenia n=349 patients over 40 months Enzyme immunoassay-confirmed HIT HITT Age (y) Surgery 59.9% 70.1% Cardiac 41.3% 36.8% Ortho 1.6% 4.6% UFH 80.1% 88.5% UFH SC 38.2% 25% LMWH 9.2% 1.1% Mortality 21% 21.8% Cost $122,191 $112,281 Baroletti S et al. Thromb Haemost. 2008;100:

22 THE HIGHER THE ELISA, THE MORE LIKELY THROMBOSIS/ PE Any thrombosis PE Proportion with event (n=318) Anti-heparin/PF4 antibody level (OD units) Baroletti S, et al. Am J Med 2012; 125; (3): Warkentin T. Am J Med 2012; 125;(3):3-4.

23 BWH Direct thrombin Inhibitor Expense $469,129 $1,838,721 $121,346 $1,490,938 $1,369,592 23

24 Percent Increase Interfacing Pharmacy and Microbiology Systems 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% -5.0% 13.3% 16.0% 19.5% 2.7% 9.4% BWH ASP Launch -2.1% -5.1% Percent Change in Gross Antimicrobial Expenditures 0.8% -0.4% 8.3% 0.3% -3.6% 5.1% -10.0% BWH Nosocomial C. difficile Rates Contact Precautions Plus BWH Treatment Guidelines New lab testing method Source: BWH Pharmacy Financial Data * Excludes HIV& HBV ARVs

25 Outline Academic Role Education, Mentoring Writing and Publishing Guideline development Business Role Value and Efficiency Pharmacoeconomics Pharmacovigilence Patient Research Role Study development Drug Procurement Patient identification Drug Safety Clinical Role Appropriate drug & dose selection Patient engagement Therapy monitoring Guideline develpment

26 Lascaux Cave, Montignac, France Yavapai, Colorado, USA Sulawesi, Indonesia 26

27 Academic 27

28 Northeastern University Massachusetts College of Pharmacy University of Rhode Island University of New England University of Connecticut Creighton University

29 Available at: 29

30 Outline Academic Role Education, Mentoring Guideline development Critical pathways Order sets Business Role Value and Efficiency Pharmacoeconomics Pharmacovigilence Patient Research Role Study development Drug Procurement Patient identification Drug Safety Clinical Role Appropriate drug & dose selection Patient engagement Therapy monitoring Guideline develpment

31 U.S. Population using Prescription Drugs: vs U.S. Prescription Drug Expenditures (Billions) Heath United States Centers for Disease Control and Prevention. Available at: US Department of Health and Human Services. Observations in Drugs spending. Available at: pending.pdf

32 Business Role

33 Comparisons in Utilization $$$$$$$ Heparin 5000 units Enoxaparin 40 mg Betrixaban 80 mg CAR-T $373K $8500 t-pa Albumin 150,000 doses per year $ 0.83 per vial $124,000 annual spend 50,000 doses per year $ 3.70 per syringe $ 185,000 annual spend 50,000 doses per year $ 4.62 per tablet $ 231,000 annual spend $36 $5 Vancomycin Incremental Cost to replace Incremental Cost to replace Incremental Cost to replace $91,000 $46,000 - ASA Provided through McKesson Connect $0.01 $

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38 Summary Develop your skills in multiple areas. A Pharmacy leader has clinical, research, academic and business acumen. Grow and apply this skills on a daily basis. Teach these skills to the next generation so that pharmacists are viewed as being competent in any country.