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Nebraska Medical Center
Throughout pharmacy school, today’s new practitioner receives extensive training in pharmacotherapeutics, clinical pharmacokinetics and medicinal chemistry. Along with didactics, future pharmacists are introduced to the concept of pharmaceutical care.(1)
Many pharmacists today practise in disease management settings that include patient education services, therapeutic monitoring and prescriptive authority.
With this, only a small proportion of all pharmacists practise in formal disease management settings. According to the US Department of Labor, of the 230,000 pharmacists, 85% are employed in community or hospital pharmacies.(2) The remainder practise in mail-order pharmacy, pharmaceutical wholesalers, home health, federal government and clinics. Although there is no accurate number of pharmacist-operated disease management practices in the USA, it is evident that the percentage remains low.
Collaborative practice agreements are essential in allowing the pharmacist to operate disease management clinics. Laws regulating pharmacy practice are determined at the level of state government, therefore practice privileges vary throughout the country. Approximately 67% of states currently have laws that allow collaborative practice between a pharmacist and a physician.(3) Facilities under the jurisdiction of the federal government determine practice authority on a local level and provide a large majority of disease management clinics within the USA. This is particularly true within the Veterans Affairs system.(4)
The National Cholesterol Education Program (NCEP) Adult Treatment Panel III recommends the utilisation of lipid clinics and collaborative relationships between primary providers and pharmacists to enhance patient outcomes.(5)
This paper highlights two pharmacist-operated disease management clinics, with emphasis on the treatment of hyperlipidaemia. The first represents a lipid clinic in a federal facility. The second is a private practice clinic under the jurisdiction of state laws.
The pharmacy lipid clinic at the Veterans Affairs Medical Center in Grand Island, Nebraska, provides disease management services, including independent prescriptive authority. In this federally supported facility, pharmacists are credentialled at the local level as approved by a committee of physicians. More than 3,000 individuals have utilised the services of this clinic since its inception in 1995.
Patients are referred by their primary provider following diagnosis. The referral is completed electronically through a paperless charting system. During the initial visit, the pharmacist completes an extensive medical history interview along with review of information received from the chart and referring provider. Ten-year cardiovascular event risks are calculated in association with the patient to emphasise the need for therapy.
The pharmacist then provides extensive education on therapy options, which include lifestyle changes and pharmacotherapy. Current national guidelines on the management of hyperlipidaemia are followed and serve as the basis for treatment decisions.(5) Finally, a therapeutic plan is established in concert with the patient. Charting is completed electronically.
Prescription and lab orders are entered in the computer by the pharmacist and submitted to the pharmacy and laboratory, respectively. Orders are signed electronically. Follow-up visits are scheduled by clerical staff. If complications or complex patients arise, the computer system allows the pharmacist to submit the progress note electronically to the provider for alert and co-signature. Uncomplicated visits require no co-signature but are available for review by the provider at the patient’s next formal physician visit.
The second clinic is a private practice established to manage the lipid components of metabolic syndrome. It includes a collaboration of physician, pharmacist, dietician, nurse, mental health therapist and an exercise trainer. The programme provides intensive group education in monthly classes attended by all participants. Individual exercise training is delivered by the exercise trainer. Approximately 100 patients are currently enrolled in this programme.
In addition to group sessions, the pharmacist provides individual medical history and lab assessment. Medication therapy is then modified by the pharmacist according to an established local protocol. Prescription modifications are telephoned to local pharmacies.
Documentation on the collaborative agreement between the pharmacist and the physician is on file with the state health department as approved by the pharmacy and medical boards. This type of practice setting is relatively new to the state of Nebraska as well as many other states.
Both clinic settings are well received by physicians and patients. Physicians are pleased with the detailed information provided to the patient and the achievement of therapeutic goals. In federally funded facilities, the physician is encouraged to see patients less frequently and utilise physician extenders to manage chronic disease states as a method to reduce costs.
In private practice, the setting is more challenging as many physicians see the pharmacist as competition. Financial reimbursement is currently not solicited for this private clinic, with funding received through grants and private donations. Patients express satisfaction through better knowledge of the disease state and understanding of therapeutic benefits.
Today’s new US pharmacists are well trained to deliver quality disease management through pharmaceutical care. With this, only small proportions are moving into such practices. Factors inhibiting the process may include poor financial reimbursement for cognitive services, provider acceptance, inadequate laws or regulations, lack of confidence of older pharmacists and pharmacist shortages.
This article highlights two examples of pharmacy disease management lipid clinics. Each has highly different resources and support. As state laws regulating pharmacy advance to include provisions for collaborative relationships, young pharmacists should take advantage. Older pharmacists may require additional training to refresh knowledge.
Financial reimbursement is an extensive limitation. With the new Medicare D programme in the USA, cognitive services are potentially reimbursable. Pharmacists must now seize the opportunity to move into chronic disease management practices and provide quality healthcare.