Study demonstrates value of consultant pharmacists

Janice Feinberg, Pharm.D., FASCP, research manager for the ASCP Research & Education Foundation, presented the most recent phase III findings of the Fleetwood Project, a three-phase initiative aimed at demonstrating the impact of consultant pharmacy services on patient outcomes.

Feinberg and her colleagues took the results from phases I and II and asked themselves, "Can we take this Fleetwood model and implement it in a more typical long-term care pharmacy?" Phase II of the project involved a prospective drug regimen review at the time of dispensing, direct communication with the prescriber, patient assessment by the consultant pharmacist, and formalized pharmaceutical care planning. Phase III was basically phase II implemented on a much larger scale, according to Feinberg, and was performed at the pharmacy services division of Neil Medical Group, a long-term pharmacy provider in Kinston, N.C.

One important thing to come out of phase III, said Feinberg, was the creation of a Web-based database that allowed the internal pharmacist to upload intervention information on a specific patient; the consultant pharmacist was thus able to have access to the latest information on-site in the nursing home.

Additionally, treatment algorithms were developed for inappropriate medications. One problem, according to Feinberg, is that many drugs are not appropriate for elderly patients, due to anticholinergic side effects. But in many cases there may not be a suitable alternative. Instead of restricting the use of these drugs, the group focused its intervention on early recognition of side effects by creating "alert cards" to be sent to the nurse with each new prescription and refill. Nurses were encouraged to look for these side effects and report them.

Attendees of the presentation were given the Fleetwood Toolkit 1.0, containing information on the three Fleetwood Project phases; the treatment algorithms developed; alert cards for anticholinergics and digoxin (warning physicians that doses over 0.125 mg may be inappropriate); and a propoxyphene letter to physicians, highlighting the fact that there may be more appropriate drugs for pain in the elderly due to propoxyphene's long half-life and pro-arrhythmic effects. Instead, pharmacists recommended acetaminophen for mild pain and hydrocodone bitartrate/ acetaminophen for moderate pain.

"[The study] was very difficult to implement but definitely worthwhile," Feinberg said. "We've developed good tools. Although the final data from the third and final phase have not yet been analyzed, I think the results will show positive outcomes." She concluded by stating that she believes the Fleetwood Project is the most important research initiative to be done by any pharmacy group.

Also at the conference, the results of ASCP's latest annual survey of consultant pharmacists, medical directors, directors of nursing, and nurse practitioners who work in long-term care were shared with the audience. In 2005, over 13,000 professionals were surveyed. Twenty-nine percent of medical directors said they utilized consultant pharmacists regularly, while 45% did sometimes. "This indicates a pretty good utilization," said William Simonson, Pharm.D., FASCP, CGP, past president of ASCP.

Asked about the role of the consultant R.Ph.s, medical directors were supportive of their involvement in in-service education, identifying drug interactions, providing valuable alternative suggestions, and as a source of drug information. They exhibited slightly less support both for the notion that Medicare should pay for medication management services provided by consultant pharmacists and for a pharmacist's involvement in identifying underdiagnosed and undertreated patients.